The incidence of “slipping a disc” in your low back or herniating an intervertebral lumbar disc, in the medical vernacular, while attempting to move that heavy filing cabinet is not uncommon. The ensuing low back pain and often accompanying radiating leg or buttock pain from a bulging disc putting pressure on your spinal nerves is also unfortunately, quite common. Dr. Jon Lurie and a collaborative team of researchers based out of Dartmouth’s Department of Medicine, Orthopedics, Health Policy and Clinical Practice set forth to assess the data of 8-years of outcome research from operative versus non-operative treatment for this debilitating back issue.
Decompression surgery to relieve disc-related spine pain is a well-researched and a highly-accepted indication for spine surgery. While in the throws of an episode of raging low back pain, the quick fix of going under the knife seems like a logical decision, but spine surgery comes with plenty of costs and risks. The questions Dr. Lurie’s team set to answer was: why does the rate of surgery vary so greatly geographically in the U.S, if the surgical option is more effective and faster to provide relief? They also aimed to add to the body of knowledge of high-quality, multiple-testing sites, with randomized controlled trials of prospective surgical (or conservatively managed) effects on patients over the long term.
This study was considered a ‘concurrent prospective randomized and observational cohort study’, as each of the 1,991 eligible participants chose either a route into randomized study (surgery vs nonsurgery) at one of 13 spine clinics participating in this Spine Patient Outcomes Research Trial (SPORT) or the observational group. The observational group got to choose their not-so-random, treatment route of surgery vs nonsurgery. There was plenty of lenience in the eight-year study for either group to opt in or crossover to the other group as their back issue and provider deemed necessary. The nonoperative group was tracked over the course of the study and received the “usual care” recommendations. These treatments were customized to the individual and included at least: physical therapy, back pain education and counseling, and medication management.
All of the enrolled participants received thorough screenings and imaging tests for eligibility (such as >6 weeks of radiating low back pain with a confirmatory MRI), outcome measures and assessments on a regular basis (6 weeks, 3 months, and 6 months, and annually thereafter). Most surgical participants had the standard bulge trimming or ‘open discectomy’ and exam of their pinched nerve root. The study gets highly complicated statistically, as the analyses were multifactorial and convoluted to best capture the longitudinal comparisons of the randomized and observational groups. Lurie et al. provided plentiful and excellent flow diagrams cited in the original paper for those that want to peruse the detailed statistical intricacies behind such analyses as “intent-to-treat” versus “as-treated” groupings.
The results reiterated the hypothesis that usually, effective and selective surgery relieves radiating low back pain. Over the course of this 8-year study, more measurable improvements were “clinically significant” in all of the main outcome measures (ie. bodily pain, physical function, perceived disability) for the surgical group than those who remained nonoperative. However, both groups experienced heavy amounts of statistically challenging “crossover”, as humans tend to change their mind on the question of: Should I Get My Sciatica Relieved Surgically, Or Should I Wait? The common exception for both groups was neither returned to prior work status. Or once you ‘blow a disc’ hoisting that filing cabinet up the stairwell, you’re less likely to return to moving heavy office equipment regardless of choosing surgery or conservative care for your back. The study goes on to throw the conclusive bone to those deliberating this costly surgery, that “even among patients with strong surgical indications, many (34%) remained in the nonoperative group out to 8 years”. Take comfort in conservative rehabilitative care and do your core stabilization exercises and spine stretches if surgery doesn’t sound like your calling, as improvements in “sciatica bothersomeness” happened in both groups.
Jon O. Lurie, MD, MS, et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation – Eight-Year Results for the Spine Patient Outcomes Research Trial. In Spine. 2014, Volume 39, Number 1. Pp. 3-16.
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