When Do You Try Discectomy?

Results of this Study | When to Operate: the Expert's opinion ]

Rothoerl RD , et al. "When should conservative treatment for lumbar disc herniation be ceased and surgery considered?" Neurosurg Rev - 2002; 25:162-165

When is enough, enough? When do you throw in the towel, forget the conservative care, and try a discectomy to rid yourself of that terrible burning pain in your lower limb? This is a very tough but vital question; unfortunately, it doesn't have a perfect answer.

For some patients, the choice is much easier. Here are the indications for 'Immediate' Disc Surgery: severe intractable back and leg pain, progressive loss of motor functions (progressive loss of muscle power and function in the lower limbs), and/or the development of cauda equina syndrome (loss of the ability to control ones poop and pee) (51). For all other sciatica sufferers, however, surgical removal of that compressive disc herniation is only an elective and one must take great care NOT to have surgery when all the indications are not present, as I have learned the hard way!

One must be very carefully NOT to jump into an unnecessary operation offered by an over zealous spine surgeon, for it will often lead to a less than favorable result. In fact, inappropriate patient selection continues to be the number one cause for failed discectomy surgery (1). Weber's famous Volvo Award winning investigation of 1983 also suggested that about 60% of surgically treated patients are submitted to an unnecessary surgery for, according to their research, these patients would have improved to the same degree with only the passage of time (2).

Let us examine the only recent and respectable research paper on this important topic. In 2002, Rothoerl not only studies the impact of 'pre-surgery symptomatology time' but also reviews some of the other similar studies.   His study tried to answer the question; if the duration of ones pre-surgery symptoms and neurological findings made any difference in the out-come of surgery.

"It is clearly a mistake and potentially dangerous obstinately carry out conservative treatment in all patients with herniated discs, especially because many reports indicate that patients with long-standing preoperative symptoms have fewer chances of obtaining satisfactory results from surgery than those whose symptoms are of short duration." (23, 12, 24, 25)

"Only a very few studies in the recent literature have deal with the 'timing of surgery' for herniated lumbar discs."   In 1998, Graver et al. followed the outcome of 122 patients suffering from disc herniation.   Low body height (shortness), obesity, and long duration of sickness absents were all shown to be negatively associated with the outcome of surgery but the duration of symptoms was not studied (27).   Vucetic et al. also did NOT study the duration of symptoms pre-surgery.   They did note the following: a duration of sciatica less than 7 months, no pre-operative comorbidity, being younger than 41 years, male gender, and no previous non spinal surgery were all positive predictors of good outcome from lumbar surgery (28).   The only other research paper that looks at 'pre-surgery symptom duration' was done by Hurme et al. in 1987.   They found that the best surgical outcome occurred when the sciatica suffering patient was operated on with in 2 months from the onset of severe sciatica. (12)

The Study:

In this German study, 219 patients with a lumbar disc herniation, sciatica, and neurological findings, underwent their first ever surgery at one level via "conventional discectomy via extended interlaminar fenestration".   Stenosis patients & laminectomy patients were excluded. These patients were placed into three groups based on when surgery was performed in time relation to the onset of symptoms and sensory deficit, and motor deficit: < 30days, between 30 to 60 days, and > 60 days. The initial pre-surgery exam was as follows:

At 10 months: (298 days) 204 of the patients (93%) of these patients were evaluated by an independent examiner.   Outcome was evaluated using the Prolo scale:

Favorable Outcome: 8 to 10 points

Unfavorable Outcome: 2 to 7 points

Results:

60% of the patients had a "favorable outcome", i.e., 8 to 10 on the prolo scale, at about 10 months post discectomy.

Longer duration of pre-operative pain, sensory deficit, and smoking, were all 'unfavorable predictors of surgical outcome'.

Suffering pain and sensory deficit (not motor deficit) from a disc herniation for over sixty days, without surgery, was shown to have a statistically worse outcome than for patients who had their surgery within the 60 days.

In other words, if you're NOT improving with conservative care and you have been suffering sciatica pain and/or sensory change in a dermatomal pattern, your chances for a successful surgery go down hill after 60 days.

How long should radiculopathy secondary to disc hernation be allowed to continue? Here's what the experts say: (see full list of investigations: Here)

Conclusion of Rothoerl :  

"Due to our findings, we recommend conservative treatment for up to 2 months. If there is no improvement in symptoms and signs, surgery should then be considered without further conservative treatment options." Please people, understand that if you are improving slowly, then you should continue conservative care. In fact the Saal brothers published a very famous and often quoted studies that show conservative care can achieve good outcomes even in surgical sized disc hernation (here).

References:

1) Herron LD, Turner J. "Patient selection for lumbar laminectomy and discectomy with a revised objective rating system." Clin Orthop 1985;199:145-52.

2) Weber H. 1983 Volvo Award Winner: "Lumbar Disc Herniation: A controlled, prospective study with ten years of observation." Spine 1983;8:131-40

10) Dauch WA, et al. "predictors of treatment success after microsurgical operation of lumbar intervertebral disc displacements" Zentralbl Neurochir - 1994; 55:144-155

11) Dvorak J, et al. "The outcome of surgery for lumbar disc herniation."   Spine -1988; 13:1418-22

12) Hurme M and Alaranta H "Factors predicting the result of surgery for lumbar intervertebral disc herniation.   Spine - 1987; 12:933-938

13) Jonsson B, et al. "Patient-related factors predicting the outcome of decompressive surgery." Acta Orthop Scand Suppl - 1993; 251:69-70

14) Postacchini F, "Management of herniation of the lumbar disc." J Bone Joint Surg - 1999; 81-B :567 -576

15) Bloch R, "Methodology in clinical back pain trials" Spine - 1987; 12:430-432

16) Hakelius A, "Prognosis in sciatica: A clinical follow-up of surgical and nonsurgical treatment."   Acta orthop Scand (Suppl) - 1970; 129

17) Nashold BS, et al. "Lumbar disc disease: A twenty-year clinical follow-up study." Saint Louis , Mosby, 1971

18) Birkmeyer NJO, Weinstein JN, et al. "Design of the Spine Patient Outcomes Research Trial (SPORT)." Spine - 2002; 27(12):1361-1372

19) Saal JA, Saal JS, "Nonoperative Treatment of Herniated Lumbar Intervertebral Disc with Radiculopathy." Spine - 1989; 14(4):431-437

20) Burton C, Kirkaldy-Willis W, et al. "Causes of failure of surgery on the lumbar spine." Clin Orthop 157:191-199 1981

21) Postacchini F, "Management of Herniation of the Lumbar disc: Review article" J Bone Joint Surg [Br] 1999; 81- b( 4):567-576

22) Birkmeyer NJO, Weinstein JN, et al. "Design of the Spine Patient Outcomes Research Trial (SPORT)." Spine - 2002; 27(12):1361-1372

23) Chabra MS, et al. "Should fusion accompany lumbar discectomy?" Clin Orthop 301:177-180

24) Postacchini F (1998) Surgical treatment. In: Postacchini F ( ed ) Lumbar disc herniation.   Springer, Berlin Heidelberg New York

25) Surin VV, (1977) "Duration of disability following lumbar disc surgery."   Acta Orthop Scand 18:466-471

26) Rothoerl RD, et al. "When should conservative treatment for lumbar disc herniation be ceased and surgery considered?" Neurosurg Rev - 2002; 25:162-165

27) Graver V, et al. "Background variables in relation to the outcome of lumbar disc surgery." Scand J Rehab Med - 1998; 30:221-225

28) Vucetic N, et al. "diagnosis and prognosis in lumbar disc herniation." Clin Orthop Rel Res - 1999; 361:116-122

50) Ng L, Sell P. “Predictive Value of the Duration of Sciatica for Lumbar Discectomy: A Prospective Cohort Study.” J Bone Joint Surg Br 2004; 86B:546-9

51) Postacchini F, "Results of surgery compared with conservative management for lumbar disc herniations" Spine - 1996; 21(11):1383-1387

66) Ng LC, Sell P. "Predictive value of the duration of sciatica for lumbar discectomy: A prospective cohort study." J Bone Joint Surg Br. 2004 May;86(4):546-9.