Patients With Persistent Low Back Pain and Nerve Root Involvement

To Operate, or Not to Operate, That Is the Question

Tom Petersen, PhD; Carsten B. Juhl, PhD; Gilles L. Fournier, MD


Spine. 2020;45(7):483-490. 

In This Article

Abstract and Introduction


Study Design: Prospective cohort study.

Objective: The aims of this study were to evaluate the outcome of surgical and nonsurgical treatment for patients with lumbar herniated disc (LHD) or lumbar spinal stenosis (LSS) after 2 years and to identify predictors for nonsuccess.

Summary of Background Data: Studies regarding the clinician's ability to identify patients with a poor prognosis are not in concurrence and further studies are warranted.

Methods: This study included 390 patients with LHD or LSS referred for surgical evaluation after unsuccessful conservative treatment. Nonsuccess was defined as a Roland-Morris Disability score above 4 (0–23) or a Numeric Rating Scale back and leg pain score above 20 (0–60). Uni- and multivariate logistic regression analyses were used to investigate potential predictive factors including sociodemographic characteristics, history findings, levels of pain and disability, and magnetic resonance imaging findings.

Results: Rates of nonsuccess at 2 years were approximately 30% in surgically treated patients with LHD, approximately about 60% in patients with LSS for disability, and 30% and 40%, respectively for pain. For the main outcome variable, disability, in the final multiple logistic regression model, nonsuccess after surgery was associated with male sex (odds ratio [OR] 2.04, 95% confidence interval [CI]: 1.02–4.11, P = 0.04), low level of education (OR 2.60, 95% CI: 1.28–5.29, P = 0.01), high pain intensity (OR 3.06, 95% CI: 1.51–6.21, P < 0.01), and widespread pain (OR 3.59, 95% CI: 1.36–9.46, P = 0.01).

Conclusion: The results indicate that the prognosis for patients referred for surgery with persistent LHD or LSS and unsuccessful conservative treatment is substantially better when surgery is performed as opposed to not performed. The predictive value of the variables male sex, low level of education, high pain intensity, and widespread pain location found in our study are partly in accordance with results of previous studies. Thus, our results warrant further investigation until firm conclusions can be made.

Level of Evidence: 3


Low back pain (LBP) radiating below the gluteal fold is commonly caused by a lumbar herniated disc (LHD) or a lumbar spinal stenosis (LSS).

A recent systematic review found no statistically significant differences in 1 to 2 years outcome between surgery versus conservative management of sciatica due to an LHD.[1] Results regarding LSS are reported to be inconclusive[2] or showing a slight benefit in favor of surgery at 1 and 2 years follow-up only.[3] Individual studies report overall nonsuccess rates of LHD surgery between 24% and 44% depending on the outcome measure.[4–6] The 1-year success rates of the Main and SPORT studies were 80% for the surgically treated patients and approximately 60% for the nonsurgically treated.[6–8] Within the field of LSS, a recent systematic review found that patients experience rapid symptom reduction after surgery, but should still expect to experience mild-to-moderate pain and disability 60 months later.[9]

In order to improve the benefit of surgery several studies have sought to identify predictors that might identify patients having an increased likelihood of nonsuccess after back surgery. The most recent systematic review within the field of LHD found the following preoperative factors to be predictive of poor outcome after disc surgery: intact annulus, long duration of sick leave, and severe baseline symptoms. Age, sex, motor deficits, or Modic changes type 1 appeared to exert no significant influence on outcome.[10] Another review, using a slightly different methodology, found no predictive value of additional spinal stenosis or disc morphology; that is. protrusion, sequestration, or posterolateral location.[11] Within the field of LSS, the most recent systematic review found moderate versus severe central stenosis to be predictive of poor outcome 2 years after surgery.[12] In order to pursue these issues further, the current study was designed to explore predictors based on patient characteristics and magnetic resonance imaging (MRI) findings that could assist the clinician in identifying the most favorable treatment to the individual patient.

The aim of this cohort study was to report outcome of surgical as well as non-surgical treatment for patients with LHD or LSS after unsuccessful conservative treatment and to identify predictors for nonsuccess.