Surgical vs. Nonoperative Treatment for Lumbar Disk Herniation December 5, 2006
Posted by healthweb in Neurology, Surgery.8 comments
The Spine Patient Outcomes Research Trial (SPORT) Observational Cohort.(JAMA, November 22/29, 2006)
Posted by Dr. David Weir
Background:-Lumbar discectomy is the most common surgical intervention for sciatic-like pain in the United States. -The effectiveness of surgery vs. nonoperative treatment of back and leg symptoms remains controversial.
Methods:
-Prospective observational study. Patients were evaluated at 6 weeks, 3 months, 6 months, 1 year, and 2 years of follow-up.
-Inclusion criteria- 18 years or older with intervertebral disk herniation and persistent symptoms despite some nonoperative treatment for at least 6 weeks. Radicular pain, positive straight leg test, corresponding neurologic deficit with disk herniation on CT or MRI that corresponded to clinical symptoms.
-Exclusion criteria- prior lumbar surgery, cauda equine syndrome, scoliosis greater than 15 degrees, segmental instability, vertebral fractures, spine infection or tumor, inflammatory spondyloarthropathy, pregnancy, unwillingness to have surgery within 6 months.
-Primary endpoints- Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) bodily pain and physical function scales and the AmericanAcademy of Orthopedic Surgeons version of the Oswestry Disability Index (ODI).
-Secondary endpoints- Self-reported improvement, work status, and satisfaction with current symptoms and care.-The study was powered to detect a 10-point difference in the SF-36 and a comparable difference in the ODI. -743 patients enrolled, 521 chose surgery, 222 chose nonoperative care. At 2 years 96%of the surgery arm underwent surgery and 22% of the nonoperative care group underwent surgery. Results:
-In the surgery group the adjusted change in the SF-36 score at 2 years was 42.6 for bodily pain and 43.9 for physical function. The change in the ODI score at 2 years was -37.6.- In the nonoperative group the adjusted change in the SF-36 score at 2 years was 32.4 for bodily pain and 31.9 for physical function. The change in the ODI score at 2 years was -24.2.-The difference between the two groups at two years (treatment effect) was 10.2 (95%CI, 5.9-14.5) for SF-36 bodily pain, 12.0 (95%CI 7.9-16.1) for SF-36 physical function, and -13.4 (95%CI -17.0 to -9.7) for ODI score. (Higher SF-36 scores indicate less severe symptoms, a lower ODI score indicates less severe symptoms). (more…)
