Hospitalization for Disc Herniation is a Bad Omen!

Nykvist F, et al. "A prospective 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation" Int. Disabil. Studies - 1989; 11(2):61-67

The bottom line of this well written investigation was: If you sciatica is so severe you need hospitalization, you better have a surgery! The conservative group did not do so well in this study.

This was a non-randomized prospective Finnish study of 276 patients that were hospitalized for suspected disc herniation. Two-thirds of the patients were operated upon, and the other 1/3 underwent conservative care ONLY!   They were followed at four phases: Before the hospital, in the hospital, at 1 year and finally at 5 years.   I would note that this was very well written with excellent follow-up (6 - 8 hour evaluations!)   The categories of disability were very well defined in accordance to WHO (world health organization) classification. It's a shame that the Weber's Volvo award winning study didn't use these definitions for improvement!   Note that the DOI (date of injury) was the date the patient became severely acute.   The "initial phase" was on average 3 months long, although it varied.

Sciatica was defined as: "Unilateral pain radiating to mid-calf or below, which is more severe than back pain or paresthesia localized to a dermatome."

Inclusion criteria :   < 55 years of age, not retired, and a local resident.   357 patients were selected initially. All patients had myelograms and exams prior to their choice of treatment.   Absolute indications for surgery were: 1) Cauda equina syndrome, 2) massive paresis (motor loss), 3) intractable (not easily cured or controlled) pain.

220 patients were operated on via flaval fenestration and partial laminectomy.   (15 were not counted for they had stenosis, no disc herniation, tumor, and adhesions).  

122 patients were treated conservatively; first in the hospital, and later on an out-patient basis.   Treatment included ESI, exercise, rest, and traction.

322 or these patients (94%) attended a follow-up at one year. 283 (83%) showed up at 5 years. (80% and above is considered an effective study).

276 patients attended both the 1 year and 5 year follow-up. It was decided to completely eliminate the patients who did not show up for either evaluation. 179 surgery patients and 97 non-surgery patients.

Results:

Definitions of Outcome:

"No handicap" is defined as no problems at work or with leisure activities.

" Mild handicap " is defined as an intermittent inability to follow customary occupation or leisure time activities.   On most days there are no symptoms of lower back pain and need for sick leave is uncommon."

"Moderate handicap" is defined as an inability to participate in all the activities associated with their customary occupation or recreation.   Low back pain symptoms are almost chronic and the need for sick leave occurs every now an then.

" Severe handicap " is defined as: individuals are able to follow only a modified or alternative full-time occupation and need special arrangements at the work place; strenuous leisure-time activities are almost totally restricted.   Low back pain and need for sick leave are chronic, and individuals may have received a part-time pension.

Patient Self-Assessment:

The 'Re-Operation Rate' was 13.8% (25 out of 179), mostly as a result of recurrent disc herniation at the same level, same side.   The five year outcome was not good for this group!   84% landed in the 'Severe handicap group'!   6 from the non-operation group had needed an operation during the five year period.   All of them ended up in the "severe handicap group". The retirement rate was "double" for that of the one time herniation groups (36% versus 18%).   (84% were in the severe handicap groups versus 36% of the one time operation groups.)  

Conclusions:   Being hospitalized for sciatica is a bad omen, especially if you don't get or qualify for surgery.

At 5 years, 68% of the surgically treated patients still had pain in a sciatic distribution, versus 82 % of the non-surgically treated patients, which is consistent with several other earlier studies (007, 008).  

There have been other studies that have shown different results for lingering sciatic pain: 12 to 79% (19 ,20,21,22 - within this article).   The authors stated the reasons of the variations were because of poor experimental technique.

WHO Disability Results:

• At 5 years only 57% (102 of 179 patients) of the surgical patients were termed a success (no to mild handicap) with about 20% being pain free. (50% self assessed themselves as being "much better" when compared to how they were at their worst (in the hospital)) (36% were in the true severe categories).   43% were moderate to severely handicap.
  
• At 5 years only 38% (37 of 97 patients) of the non-surgical patients were termed a success (no to mild handicap) with about 2.5% being pain free.   (19% self assessed themselves as being "much better" when compared to how they were at their worst (in the hospital)) 62% were moderately to severely handicap!

• 23% of the surgical group deteriorated after one year into the moderate to severe handicap group.
• 43% of the non-surgical group deteriorated after on year; into the moderate to severe handicap group.

A worsening trend: A deteriorating situation was observed in the non-surgical group by comparing there pre-flare-up disability to their 5 year disability (although the author warns that the pre-hospitalization classification were done on patient memory one year after the fact).   A switch from mild to moderate/severe was much greater in the non-surgical group.

One year predicts your future : Of the non-surgical group, only 20% 'rose from the dead' and increased their handicap from the moderate/severe group into the 'no to mild group'.   Of the surgical group, only 12.5 (7 out of 56) increased into the success zone. Note: Their one year started at their hospitalization date, many had "initial phase' pain that was on average - 3 months in duration.   Maybe I've got a little more time.