For patients with low back pain and other symptoms caused by herniated discs, surgery provides better results than nonsurgical treatment, according to a study in the December 1 issue of Spine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry.

At four years’ follow-up, surgery yields better results in almost every outcome measured, according to the new study one of the few direct comparisons of surgery versus nonsurgical treatment for herniated discs. The lead author was Dr. James A. Weinstein, D.O., M.S., of the Dartmouth Medical School, Hanover, N.H.

The Spine Outcomes Research Trial (SPORT) included 1,244 patients with herniated discs in the lumbar (lower) spine, with back pain, leg pain, and other symptoms caused by pressure on the spinal nerve roots. The presence of a herniated disc was confirmed by imaging studies. The patients were treated at 13 spine clinics across the United States.

Five hundred one patients were randomly assigned to treatment with surgery, called discectomy; or nonsurgical treatment, including physical therapy, exercise, and pain relievers. Another group of 743 patients were permitted to choose between treatments: 521 chose surgery and 222 chose nonoperative care. Pain, functional ability, and other outcomes were compared at up to four years’ follow-up.

Pain and other outcomes are better with surgery

In the randomized group, patients assigned to surgery had better outcomes. It was difficult to assess the true benefits of surgery, because about 40 percent of patients initially assigned to nonsurgical treatment wound up undergoing surgery within the first year. Of patients who initially chose nonsurgical treatment, 20 percent underwent surgery within one year.

On combined analysis including all patients, pain scores were significantly lower for patients undergoing surgery an average of 15 points lower on a 100-point pain scale. Surgery was also associated with greater improvement in measures of physical functioning and disability. The only outcome that was not significantly better in the surgery group was the percentage of patients working: about 20 percent of patients in both groups had not returned to work.

The improvement in outcomes with surgery was seen as early as six weeks and was still present after four years. Patients treated without surgery also showed improvement, but not as much as in the surgery group. There were few serious complications of surgery.

Lumbar disc surgery is one of the most commonly performed operations, although rates vary considerably in different regions of the United States. Past studies have suggested that surgery provides faster pain relief and recovery for patients with herniated discs. 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 to surgical treatment. As in the SPORT study, this tends to underestimate the benefits of surgery.

On analysis carefully controlling for other factors, “[P]atients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over four years, compared to patients treated nonoperatively,” Dr. Weinstein and coauthors conclude. It is not clear why these improvements don’t increase the number of patients returning to work. The researchers are performing a further analysis to assess the costs versus benefits of treatment for herniated discs among patients on workers’ compensation.