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Lumbar Discectomy Outcomes Vary by Herniation Level in the Spine Patient Outcomes Research Trial

¹ Multidisciplinary Clinical Research Center (J.D.L., B.H., T.D.T., P.A.B., W.A.A., J.W.F., and J.N.W.), Department of Medicine, Dartmouth Medical School (J.D.L.), and the Dartmouth Institute for Health Policy and Clinical Practice (J.N.W.), Dartmouth-Hitchcock Medical Center (S.C.F.), One Medical Center Drive, Lebanon, NH 03756. E-mail address for J.D. Lurie: jon.d.lurie{at}dartmouth.edu

Investigation performed at the Multidisciplinary Clinical Research Center, Dartmouth Medical School, Lebanon, New Hampshire

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS; U01-AR45444-01A1) and the Office of Research on Women's Health, the National Institutes of Health; and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention. The Multidisciplinary Clinical Research Center in Musculoskeletal Diseases is funded by NIAMS (P60-AR048094-01A1), and one author received a Research Career Award from NIAMS (1 K23 AR 048138-01). Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.

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Methods: The combined randomized and observation cohorts of the Spine Patient Outcomes Research Trial were analyzed by actual treatment received stratified by level of disc herniation. Overall, 646 L5-S1 herniations, 456 L4-L5 herniations, and eighty-eight upper lumbar (L2-L3 or L3-L4) herniations were evaluated. Primary outcome measures were the Short Form-36 bodily pain and physical functioning scales and the modified Oswestry Disability Index assessed at six weeks, three months, six months, one year, and two years. Treatment effects (the improvement in the operative group minus the improvement in the nonoperative group) were estimated with use of longitudinal regression models, adjusting for important covariates.

Results: At two years, patients with upper lumbar herniations (L2-L3 or L3-L4) showed a significantly greater treatment effect from surgery than did patients with L5-S1 herniations for all outcome measures: 24.6 and 7.1, respectively, for bodily pain (p = 0.002); 23.4 and 9.9 for Short Form-36 physical functioning (p = 0.014); and –19 and –10.3 for Oswestry Disability Index (p = 0.033). There was a trend toward greater treatment effect for surgery at L4-L5 compared with L5-S1, but this was significant only for the Short Form-36 physical functioning subscale (p = 0.006). Differences in treatment effects between the upper lumbar levels and L4-L5 were significant for Short Form-36 bodily pain only (p = 0.018).

Conclusions: The advantage of operative compared with nonoperative treatment varied by herniation level, with the smallest treatment effects at L5-S1, intermediate effects at L4-L5, and the largest effects at L2-L3 and L3-L4. This difference in effect was mainly a result of less improvement in patients with upper lumbar herniations after nonoperative treatment.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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