Nonsurgical Treatment of Lumbar Disk Herniation

Are Outcomes Different in Older Adults?

Pradeep Suri, MD; David J. Hunter, MBBS, PhD; Cristin Jouve, MD; Carol Hartigan, MD; Janet Limke,MD; Enrique Pena, MD; Ling Li, MPH; Jennifer Luz, BA; James Rainville,MD

Disclosures

J Am Geriatr Soc. 2011;59(3):423-429. 

In This Article

Abstract and Introduction

Abstract

Objectives: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).
Design: Prospective longitudinal comparative cohort study.
Setting: Outpatient specialty spine clinic.
Participants: One hundred thirty-three consecutive patients with radicular pain and magnetic resonance–confirmed acute LDH (89 younger, 44 older).
Intervention: Nonsurgical treatment customized for the individual patient.
Measurements: Patient-reported disability on the Oswestry Disability Index (ODI), leg pain intensity, and back pain intensity were recorded at baseline and 1, 3, and 6 months. The primary outcome was the ODI change score at 6 months. Secondary longitudinal analyses examined rates of change over the follow-up period.
Results: Older adults demonstrated improvements in ODI (range 0–100) and pain intensity (range 0–10) with nonsurgical treatment that were not significantly different from those seen in younger adults at 6 month follow-up, with or without adjustment for potential confounders. Adjusted mean improvement in older and younger adults were 31 versus 33 (P=.63) for ODI, 4.5 versus 4.5 (P=.99) for leg pain, and 2.4 versus 2.7 for back pain (P=.69). A greater amount of the total improvement in leg pain and back pain in older adults was noted in the first month of follow-up than in younger adults.
Conclusion: These preliminary findings suggest that the outcomes of LDH with nonsurgical treatment were not worse in older adults (≥60) than in younger adults (<60). Future research is warranted to examine nonsurgical treatment for LDH in older adults.

Introduction

Lower extremity pain in the setting of low back pain affects 12% of older men in the community-based population[1] and 21% of older adults in retirement communities.[2] Lumbar disk herniation (LDH) is a common cause of these symptoms and most typically manifests as a lumbosacral radicular syndrome: a combination of one or more of radicular pain, paresthesia, sensory changes, motor weakness, and impaired reflexes in the distribution of one or more lumbosacral spinal nerve roots in the lower extremity.[3,4] A classical dichotomy has been prominent in spine care whereby LDH is considered a clinical entity common mainly to younger adults, with a shift to a predominance of degenerative lumbar spinal stenosis (LSS) in older adults.[5] The view that LDH is rare in older adults is echoed in scientific reports and textbooks of spine care,[6–9] but other reports caution that LDH in older adults is more common than previously believed.[10–12] The prevalence of LDH in older adults is of particular importance because the outcomes with nonsurgical treatment of LDH are favorable in the majority of individuals,[13] whereas dramatic improvements in LSS with nonsurgical treatment are seen less commonly.[12]

Decompressive lumbar spinal surgery for LDH and LSS typically involves removal of a portion of the intervertebral disk (diskectomy), removal of the spinal lamina (laminectomy or laminotomy), or both. Rates of laminectomy and diskectomy in the Medicare population have shown steady increases over recent decades and exceed the rates of growth in younger populations.[14] Higher rates of increase in surgical procedures in older adults may be due to the increasing recognition that spine surgery in older adults can be performed safely in properly selected patients.[11,15] Another explanation for increasing rates of surgical procedures may be related to the perception of clinicians that the outcomes of nonsurgical treatment of LDH are poorer in older than younger adults. Various reports in the surgical literature have suggested poor outcomes with nonsurgically treated LDH in older adults.[16–18] In a landmark study of LDH by Henrik Weber, older age was the only characteristic associated with a poor outcome at multiple follow-up time points.[19] Poor outcomes in older adults may be due to age-related histological and inflammatory changes in the lumbar intervertebral disk.[8,9,20–22] Furthermore, concomitant age-related degenerative changes, such as a decrease in reserve spinal canal space due to osteoarthritic joint hypertrophy, may impede the natural history of improvement typically seen in younger adults, although no prior study has examined the outcomes of LDH with nonsurgical treatment in older adults.

The current study was a prospective cohort study comparing the outcomes of the nonsurgical treatment of LDH in adults aged 60 and older with those of adults younger than 60. The objective was to determine whether older adults experienced less improvement in back-related disability and pain over a 6-month follow-up period than younger adults. It was hypothesized that the outcomes of nonsurgical treatment of LDH in older adults would be poorer than the outcomes of treatment in younger adults. To characterize rates of recovery over time, longitudinal outcome data at multiple time points were used to conduct secondary analyses examining possible differences between older and younger adults.

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