What is the efficacy of lumbar disk surgery for the treatment of low back pain (LBP)?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Answer

In the 2006 issue of JAMA, the results of 2 studies from the Spine Patient Outcomes Research Trial (SPORT) on lumbar disk surgery for persistent radicular pain are reported. [39, 265] These include a multicenter randomized clinical trial of surgical versus nonoperative care (n=501) [39] and a companion observational study of the patients who declined randomization and selected either surgery or continued nonoperative care (n=743). [265] The SPORT investigation included patients with image-confirmed disk herniations associated with concordant symptoms and signs including sciatica. Patients had experienced at least 6 weeks of radicular pain at the time of enrollment. About 20-25% of the enrolled patients had experienced recurrent episodes of sciatica for more than 6 months. Furthermore, SPORT participants reported a wide range of pain and disability at baseline.

Surgical candidates were offered enrollment in either the randomized clinical trial or the concurrent observational study. Those entering the randomized clinical trial seemed truly ambivalent regarding which treatment they preferred. Even in the group randomized to surgery, only 50% went to surgery after 3 months. The surgery group appears to have been well monitored with less than 5% complications, which overall appeared minor. Reoperation unassociated with another disk herniation was also infrequent (< 5%). In the randomized clinical trial, an intent-to-treat analysis at follow-up revealed only small differences in outcomes at 1 and 2 years. However, these finding are difficult to evaluate since only half of those in the surgery group underwent the procedure after 3 months.

Nonetheless, both treatment groups in the SPORT study were associated with clinically significant improvements, and as noted in previous studies, the differences between treatment groups diminished over time. [262, 264, 37] Those in the observational group who elected surgery had an improvement of nearly 40 points on the Oswestry Disability Index, which is huge when the minimal important difference for clinical research is considered to be 10-15 points. This degree of improvement is substantial and represents an evolution from severe disability to nearly normal function at 6 weeks after surgery.

After 1 and 2 years, the randomized trial revealed no significant differences in outcome between groups, whereas, in the observational cohort clinically and statistically significant differences in improvement were reported for patients who had surgery. However, regardless of the intervention received, most patients were satisfied with their care, and, given the high crossover rate, most received the intervention they preferred. Therefore, the SPORT study appeared to support the positive influence of decision-making by study participants. However, it is unclear whether similar improvements would be demonstrated if patients were restricted to their assigned treatment groups.

If the main benefit from surgery is that patients perceive a more rapid resolution of disabling pain, then many decisions may hinge on how badly patients feel and how urgently they desire pain relief. Furthermore, choosing surgery for LDDs may depend more on financial and psychosocial situations than medical and surgical comorbidities. Restricting functional activity to lessen LBP and sciatica may influence the patient’s decision to have surgery depending on their financial capacity to afford surgery or their capacity to maintain employment.

Nonoperative care may delay recovery, thus, individuals may be unable to manage daily necessities over an extended period of time. Delayed recovery may risk their ability to care for family, earn a living, or keep a competitive job. The slower resolution of radicular pain over 1-2 years may be diminutive when socioeconomic losses have disrupted the patient’s family, depleted lifelong savings, or led to job loss. The surgical option may be necessary despite the upfront expense or the risk of complications.

The SPORT study assumes reasonably good surgical outcomes for diskal herniation and sciatica, eg, accurate patient selection with current imaging methods coupled with an overall negligible fear of failed back surgery, up to 50-60% with fusions for LDDs even in large multicenter studies. [256, 257, 258, 259] Many patients in the SPORT study improved within a reasonable amount of time without surgery; therefore, no clear reason to strongly advocate surgery over patient preference exists. Surgery may have little to offer patients with sufficient emotional, family, and economic resources to handle mild or moderate sciatica. The SPORT data confirmed the low risk of serious problems (neurologic deterioration, cauda equina syndrome, or progression of spinal instability) when receiving nonoperative care.

However, these differences narrowed at 2 years, although the patients with surgery continued to report less pain and better functional status than those with nonoperative treatment. The SPORT study reported a nonrandomized clinical trial comparing surgery and nonoperative therapy data was difficult to interpret due to the large number of crossovers. A quality observational study was performed in tandem with the randomized trial and showed that surgery for spinal stenosis and lumbar degenerative spondylolisthesis afforded earlier and greater pain relief and improvement in functional status and these gains begin to narrow at the course of follow-up. [42, 41]

Cohort studies indicate that although more than 80% of patients have some degree of some medical relief after surgery for spinal stenosis, 7-10 years later at least one third of the patients report back pain. The patients with the most severe nerve root compression preoperatively are most likely to have symptomatic relief. Reoperation rates are in the order of 10-23% over a period of 7-10 years of follow-up. [42, 266, 267, 268, 269]


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