Surgery Best Option for Herniated Disks; Age-Related
Wear and Tear Usual Cause
Eight-year study shows better long-term outcomes with
surgery rather than non-invasive-treatment
Dec. 30, 2013 - For patients with herniated disks
in the lower (lumbar) spine, surgery leads to greater long-term
improvement in pain, functioning, and disability compared to nonsurgical
treatment, concludes an eight year follow-up study in Spine. Herniated
disks are usually a result of aging but are more common among middle-age
people than senior citizens due to activity levels of younger people.
Aging-related wear and tear is called disk
degeneration. As you age, your spinal disks lose some of their water
content. That makes them less flexible and more prone to tearing or
rupturing with even a minor strain or twist, according to
"Carefully selected patients who underwent surgery
for a lumbar disk herniation achieved greater improvement than
non-operatively treated patients," according to lead author Dr. Jon D.
Lurie of Dartmouth-Hitchcock Medical Center and the Geisel School of
Medicine and colleagues.
The results add to the evidence for surgical
treatment of herniated disks - but also show that nonsurgical treatment
can provide lasting benefits for some patients. The study has been
posted ahead of print on the journal website; it will be published in
the January issue of Spine.
No Difference in Outcomes for Assigned
The researchers analyzed data from the Spine
Patient Outcomes Research Trial (SPORT), one of the largest clinical
trials of surgery for spinal disorders. In SPORT, patients meeting
strict criteria for herniated disks in the lumbar spine underwent
surgery or nonsurgical treatment such as physical therapy, exercise, and
pain-relieving medications. Patients with herniated disks experience
back pain, leg pain (sciatica), and other symptoms caused by pressure on
the spinal nerve roots.
The current analysis included eight-year follow-up
data on 1,244 patients treated at 13 spine clinics across the United
States. About 500 patients were randomly assigned to surgery (a
procedure called discectomy) or nonsurgical treatment, although patients
were allowed to "cross over" to the other treatment.
For the remaining patients, decisions as to surgery
or nonsurgical treatment were left up to the patients and their doctors.
Standard measures of pain, physical functioning, and disability were
compared between groups.
Consistent with previous data from SPORT, patients
assigned to surgery tended to have better outcomes. However, because
many patients did not actually undergo their assigned treatment, the
differences based on "intention to treat" were not statistically
About Herniated Disk
Also called: Bulging
disk, Compressed disk, Herniated intervertebral disk, Herniated
nucleus pulposus, Prolapsed disk, Ruptured disk, Slipped disk
Your backbone, or spine, is
made up of 26 bones called vertebrae. In between them are soft
disks filled with a jelly-like substance. These disks cushion
the vertebrae and keep them in place. As you age, the disks
break down or degenerate. As they do, they lose their cushioning
ability. This can lead to pain if the back is stressed.
A herniated disk is a disk
that ruptures. This allows the jelly-like center of the disk to
leak, irritating the nearby nerves. This can cause
Your doctor will diagnose a
herniated disk with a physical exam and, sometimes, imaging
tests. With treatment, most people recover. Treatments include
rest, pain and anti-inflammatory medicines, physical therapy,
and sometimes surgery.
>> NIH: National Institute
of Arthritis and Musculoskeletal and Skin Diseases
About Back Pain
>> More links to
information on Herniated disk at
But Better Outcomes with Surgery, Based on
When outcomes were compared for patients who
actually underwent surgery versus nonsurgical treatment, significant
differences emerged. On a 100-point pain scale, pain scores averaged
about 11 points lower in the surgery group. Measures of physical
functioning and disability showed similar differences.
Surgery also led to greater improvement in some
additional outcomes, including the bother of sciatica symptoms, patient
satisfaction, and self-rated improvement.
While average outcome scores were better with
surgery, many patients had significant improvement with nonsurgical
treatment. After eight years, about one-third of patients who were
clinically indicated for surgery have chosen not to have operative
SPORT Principal Investigator Dr. James N. Weinstein
said this is significant and shows the important role that shared
decision making plays in the process: "Every patient in the SPORT study
went through shared decision-making, during which they reviewed
objective information about the risks and benefits of their treatment
"This allowed them to make an informed choice, in
line with their own values. That about a third of these patients have
continued to be satisfied with their choice is in large part due, I
believe, to their being active participants in the initial
decision-making process" Weinstein added.
Lumbar disk surgery is one of the most commonly
performed operations in the United States, although rates vary
considerably in different regions. Past studies have suggested that
surgery provides faster pain relief and recovery for patients with
herniated disks, compared to nonsurgical treatment.
However, it has been difficult to determine the
true effects of surgery - especially because of the high number of
patients who cross over from nonsurgical treatment to surgery. This
tends to underestimate the true benefits of surgery.
The long-term follow-up results from SPORT show
that, for patients with confirmed herniated lumbar disks, "surgery was
superior to non-operative treatment in relieving symptoms and improving
function." Dr. Lurie and coauthors note that the peak benefits are
achieved within six months after surgery and persist through eight
However, many patients treated without surgery
"also showed substantial improvements over time," the researchers write.
They add that patients who crossed over to surgery were more likely to
be dissatisfied with their symptoms, felt like their symptoms were
getting worse, and had initially worse physical function and disability.
The Spine journal is published by
Lippincott Williams & Wilkins,
a part of
Wolters Kluwer Health.
Recognized internationally as the leading journal in its field, Spine is an
international, peer-reviewed, bi-weekly periodical that considers for
publication original articles in the field of spine. It is the leading
subspecialty journal for the treatment of spinal disorders.
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