Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Harry N. Herkowitz, MD*,
Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan
Posted September 2008
This article adds to the growing body of prospective studies
in which authors have utilized data from the Spine Patient Outcomes Research
Trial (SPORT) to analyze lumbar disorders (herniated disc, spinal stenosis, and
degenerative spondylolisthesis).
A prior published study from SPORT compared nonoperative with
operative treatment for lumbar disc herniations1. The intent-to-treat
analysis revealed that both nonoperative and operative treatment resulted in
improvement in primary and secondary outcome measures at two years. The
improvements were greater in the surgical group but were not significant for
the primary outcome measures of the Short Form-36 (SF-36) Health Survey bodily
pain and physical function scales and the Oswestry Disability Index. The
improvement for surgery over nonoperative treatment for the secondary outcome
measures of sciatic severity (Sciatica Bothersome Index) and self-reported
outcome were significant in favor of surgery. However, that study did not assess
the differences in outcomes between the various levels of lumbar herniation or
address the location of disc herniation in terms of foraminal, far lateral, or
posterolateral.
This follow-up study stratifies the results based on
herniation level and location of the herniated disc. One of the strengths of
the information contained in this article is the large patient database
prospectively collected in the SPORT trial along with a high percentage of
complete follow-up, 81% to 93% of patients, depending on the subgroup.
A relative weakness of this study is the small number of
upper level herniations (L2-L3 or L3-L4) compared with those at the lower
lumbar levels (L4-L5 or L5-S1). However, this distribution reflects the reality
that a much greater number of herniations occur at L4-L5 or L5-S1 than at L2-L3
or L3-L4.
The results of this study positively reaffirm the surgical
treatment for patients with a herniated lumbar disc. Although patients with
lumbar herniation at any level had a better treatment effect after surgery than
after nonoperative treatment, the two-year outcome was better for patients with
upper lumbar herniations (L2-L3, L3-L4) than for those with lower lumbar
herniations (L4-L5, L5-S1). The greater improvement in radicular pain following
surgery for the upper lumbar herniations supports the results of the classic
study by Spangfort2, published over thirty years ago. As the authors
point out, this may be due in part to less satisfactory nonoperative treatment
with upper lumbar herniations. Also, the type of herniation may play a role in
outcome. Upper lumbar herniations were more likely to be foraminal or far
lateral than lower level herniations, which were more often posterolateral. Although
some of this information has been published in prior studies3,4, the
patient numbers and levels of significance make the information contained in
this study that much more powerful.
The results of this study can be applied to clinical
practice. Patients with herniated lumbar discs should receive nonoperative treatment
prior to considering surgery unless a neurologic deficit is present or the leg
pain is unbearable. Patients with L4-L5 or L5-S1 herniations may consider
longer nonoperative treatment prior to considering surgery than patients with
L2-L3 or L3-L4 herniations since nonsurgical treatment was more effective in the
lower lumbar herniation group. Since foraminal or far lateral herniations were
more common in the upper lumbar levels and nonoperative therapy was less
effective, it may be inferred that these types of herniations are less
responsive to nonoperative management than posterolateral herniations are and that
surgery may be considered earlier depending on the clinical condition of the
patient.
In summary, the value of this study reaffirms the efficacy
and safety of surgery for patients who have a herniated lumbar disc. This study
stratifies the levels of disc herniation and effectiveness of nonoperative and
operative treatment. Surgeons will find this information useful in helping to
guide and counsel patients with regard to the most appropriate treatment for a
herniated lumbar disc.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296:2441-50.
2. Spangfort EV. The lumbar disc herniation. A computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl. 1972;142:1-95.
3. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE. The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine. 1996;21:1777-86.
4. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine. 1983;8:131-40.
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