Should You Recommend Surgery or Conservative Care for Disc Herniation?

November 29, 2006

In the November 22nd issue of JAMA, the results of two studies from the Spine Patient Outcomes Research Trial (SPORT) on lumbar disk surgery for persistent radicular pain are reported.  Both these studies sought to assess the efficacy of surgery for lumbar disk herniation as compared to nonoperative treatment, including counseling, anti-inflammatory medications, injections, and physical therapy. It is important to note that specific inclusion criteria were radicular pain as well as imaging showing disk herniation.  Because a large number of study participants declined randomization, the trial included both a randomized cohort and an observational cohort who met all inclusion criteria but opted to designate their own treatment rather than being randomized. The results of theses studies are published as companion articles. Outcomes included changes from baseline as measured by a health survey with bodily pain and physical function scales, as well as satisfaction with symptoms and self-reported improvement.  In the randomized cohort of patients, there was such a high proportion of patients who crossed over between treatment strategies (only half of patients assigned to surgery received surgery within 3 months, while nearly 1/3 of those assigned to nonoperative treatment received surgery) that an intention to treat analysis was not conclusive.  However, both groups improved substantially over a 2 year period, and there was little evidence of harm in either group. In the observational cohort, the majority of patients preferred surgery to conservative care, and these patients reported greater improvements after surgery. However, the patients in this cohort were relatively more symptomatic and functionally impaired at baseline. Nevertheless, all patients with persistent sciatica from lumbar disk herniation improved in both operated and conservative care groups.

Overall, these studies suggest that, apart from patient preference, there is no compelling reason to advocate for surgery in patients with sciatica, and the risk of serious problems when receiving conservative care is minimal. Ultimately, given the limitations of this study and the high degree of crossover in the randomized group, a superior strategy has yet to be determined, and the only way to determine the proper role and benefits for these interventions may be a sham surgical trial, which, due to ethical considerations, may never be possible.

Weinstein JN et al. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006 Nov 22/29; 296:2441-50.

Weinstein JN et al. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006 Nov 22/29; 296:2451-9.

Or if you’d rather read the New York Times front page article…

 

One Response to Should You Recommend Surgery or Conservative Care for Disc Herniation?

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