Conservative vs. Surgical Treatment for Discogenic

Radiculopathy

EBMShannon O’Day 2/9/09

PICO• P: Adults, over 18 years old, with lumbar (L4-S1)

vertebral disc herniation who experience radiculopathy• I: Non-operative treatment (bed rest, exercise, steroid

injections, analgesics)• C: Surgical treatment• O: Improvement of pain/sciatica, decrease in disability,

and less recurrence of herniation and radiculopathy.

• In adults over the age of 18 with lumbar (L4-S1) vertebral disc herniation who experience radiculopathy is conservative treatment such as limited bed rest, exercise, steroid injections, and analgesics, better over surgical treatment for improvement of pain/sciatica, decrease in disability, and less recurrence of herniation and radiculopathy?

Prevalence

• The annual incidence of lumbar disc herniation with radiculopathy is approximately 1% of the population and 5-10 out of every 1000 inhabitants in the Western countries develop sciatica every year due to disc herniation.

• MRI in patients with no symptoms may show disc herniation in up to 36% of patients.

Current Treatment

• Conservative– Activity modification– Return to ADL’s and

work asap– PT– Analgesics– Injections

• Surgery– Spinal fusion– Disc replacement– discectomy

• FIGURE 1. Four concentric layers of the intervertebral disc: (1) an outer annulus fibrosus, (2) a fibrocartilaginous inner annulus fibrosus, (3) a transition zone and (4) the central nucleus pulposus (Humphreys).

Mechanism of Injury

• Changes in hydration and collagen• Annular degeneration• General wear and tear

– Constant sitting– Jobs that require lifting– Minor back pain and chronic back tiredness is an

indicator of general wear and tear that makes one susceptible to herniation on the occurrence of a traumatic event from bending to pick up a pencil, or heavy backpack from the floor.

Mechanism of injury

FIGURE 2. Distribution of load in the intervertebral disc. (A) In the normal, healthy disc, the nucleus distributes the load equally throughout the anulus. (B) As the disc undergoes degeneration, the nucleus loses some of its cushioning ability and transmits the load unequally to the anulus. (C) In the severely degenerated disc, the nucleus has lost all of its ability to cushion the load, which can lead to disc herniation (Humphreys).

Intradiscal Pressure

FIGURE 3. Relative increases and decreases in intradiscal pressure in relation to different body positions. Note that seated and bending postures apply more pressure to the disc than do standing and recumbent positions. This explains the exacerbation of symptoms of herniated disc when patients are in the former positions (Humphreys)

Mechanisms of Injury

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Prognosis

• Resolution of symptoms regardless of treatment

• In many studies of patients with radicular pain of either L5 or S1 origin, 70% had marked reduction of leg pain in 4 weeks of the onset of symptoms.

Maigne et al

• Cohort study

• 48 patients, Follow up CT’s of 48 pts with disc herniation treated conservatively

• 9 discs decreased by 25%

• 8 discs decreased by 50-75 %

• 31 discs decreased by 75-100%

• The largest herniations decreased the greatest amount

Recurrences

• Recurrences are common and may affect up to 40% of patients within 6 months.

• Similar to the initial episode, most recurrences have a favorable prognosis.

• Recurrence rates are appx the same for conservative and surgically treated patients.

- a contained disc protrusion is almost 3 times as likely to recur compared with extruded or sequestrated discs (Morgan-Hough)

Recurrences

• Hakkinen, et al.• Cohort study: Reoperations after first lumbar

disc herniation surgery: a five year follow up.• 166 patients• Overall recurrence was 10.2%• The rate of herniating the same disc was 7.4%

of the 10.2%• Pts with one operation are at a 5-12.5% risk for

further operations. The more surgeries a pt has, the less favorable the outcome.

Treatment Choices

• Conservative care or surgery???

Studies and Reviews

Peul, et al. – • Randomized control trial, 283 patients with

sciatica• Early surgery vs. 6 months of conservative

treatment.• No significant overall difference between

treatments in disability scores during first 2 years

• Improvement in sciatica was faster in surgery group, but no longer a significant difference after 6 months and continued to narrow in the next 2 years.

Wilbert B. Van den Hout, et al

• Cost utility analysis alongside a randomized trial• 283 patients• 6 months of conservative care vs. early surgery• Early surgery provided faster recovery, but the

outcomes were the same after one year.• The faster recovery time is cost effective for

surgical patients. The increase in healthcare costs were balanced out by the difference in absenteeism from work.

Hansson

• Cohort study, 1,146 patients• Cost utility analysis of surgical vs.

conservative treatment for lumbar disc herniation over a 2 year period

• Total costs for surgery was less than that of conservative care

• Surgery improved back pain, back function, and quality of life to a greater extent than conservative therapy

Mazanec, et al.

• Observational study and a randomized comparison of medical and surgical treatment of disc herniation.

• 126 patients, 10 year follow up• Surgical treatment may result in more rapid

improvement, but differences diminish over time• Patient’s preferences and comorbidities are

important factors in the choice of treatment.

Postacchini

• Review• Surgery treatment is faster at yielding a

satisfactory resolution of symptoms• More success with marked nerve root

compression, and short duration of symptoms

• Results of surgery deteriorate in the long and very long term due to recurrences of back pain and radicular symptoms.

Atlas, et al

• Cohort study• 507 patients; Long term outcomes of surgical

and conservative management of sciatica secondary to lumbar disc herniation; 10 year results.

• At 10 years 69% of surgery pts reported improvement in symptoms (61% conservative)

• Disability status at 10 years was the same for both groups

Conclusion

• Patient’s preferences, comorbidities, coping style, previous experience with surgery, and other individual factors are important in selecting treatment.

• Patients can be offered either medical or surgical treatment with reasonable confidence of a favorable outcome.

• Those with more severe, incapacitating pain may be more inclined to opt for surgery, while those with significant comorbidities may favor a more conservative approach.

• It may be time to shift from the current recommendations about the need for surgery to patients deciding on their own, with the help of the physician, which treatment strategy is best for them.

References• Atlas, SJ. Et al. (2005). Long-term outcomes of surgical and nonsurgical

menagement of sciatica secondary to lumbar disc herniation: 10 year results from Maine lumbar spine study. Spine, 15;30(8), 927-35. Retrieved on 2/6/2009 from Pubmed.

• Birkmeyer, N. J. & Weinstein, J. N. (October 16, 1999). Medical vs. Surgical Treatment for Low Back Pain: Evidence and Clinical Practice. American College of Physicians, 3. Retrieved January 18, 2009, from hppt://www.ACP.org Cochran Library.

• Chou, MD, R. Subacute and chronic low back pain: Pharmacologic and noninterventional treatment. Up To Date. Retrieved January 19, 2009, from www.uptodate.com

• Chou, MD, R. Subacute and chronic low back pain: Surgical treatment. Up To Date. Retrieved January 19, 2009, from www.uptodate.com

• Humphreys, C. S. & ECK, J. C. (February 1, 1999). Clinical Evaluation and Treatment Options for Herniated Lumbar Disc. American Family Physician, 59(3). Retrieved January 18, 2009, from AAFP.org Cochran Library.

• Hakkinen, Arja, et al. (2007). Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5 year follow up. BMC Musculoskeletal Disorders, 8(2). Retrieved on 2/6/2009 from Pubmed.

• Hansson, Elisabeth, et al. (2007). The cost-utility of lumbar disc herniation surgery. Eur Spine, 16(3), 329-337. Retrieved on 2/6/2009 from Pubmed.

• Knight, C. L., et al. Treatment of acute low back pain. Up To Date. Retrieved January 19, 2009, from www.uptpdate.com

• Kara, B., et al. (2006). One Year Outcome After Surgery for Lumbar Disc Herniation: A Comparison of Reoperated and Not Reoperated Patients. Turkish Neurosurgery, 17(1), 1-6. Retrieved January 18, 2009, from http://www.interscience.wiley.com Cochran Library

• McKechnie, Brad, DC. (2008). Nonoperative Treatment of Lumbar Radiculopathy. Dynamic Chiropractic, 11(24), Retrieved 2/6/2009 from http://www.chiroweb.com

• Mazanac, D. & Okereke, L. (August 14, 2007). Medical verses Surgical Treatment of Lumbar Disc Herniation: Implications for Future Trials. Cleveland Clinic Journal of Medicine, 74(8), 577-583. Retrieved January 18, 2009, from http://www.CJM.org Cochran Library.

• Peul, W. C., et al. (June 14, 2008). Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomized controlled trial. BMJ, 336(7657), 1355-1358. Retrieved January 18, 2009, from http:''www.pubmedcentral.nih.gov Cochran Library.

• Postacchini, F. (1996). Results of Surgery compared with Conservative management for lumbar disc herniations. Spine, 1;21(11), 1383-7. Retrieved on 2/6/2009 from Pubmed.

• Van den Hout, Wilbert, et al. (2008). Prolonged conservative care vs. early surgery in patients with sciatica from lumbar disc herniation: const utility analysis a randomised controll trial. BMJ, 14;336(7657), 1351-1354. Retrieved on 2/6/2009 from Pubmed.

• Wikipedia. Spinal disc herniation. http://wikipedia.org.