Surgery v. Conservative Care for HNP

5 Year Outcome | 10 Year Outcome (up-date)

Atlas SJ, et al. "Surgical & nonsurgical management of sciatica secondary to a lumbar disc herniation: Five year outcomes from the Maine Lumbar Spine Study." Spine - 2001; 26(10):1179-1187: AND : Atlas SJ, Deyo RA, et al. 'Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study.' Spine. 2005 Apr 15;30(8):927-35

This famous large-scale prospective non-randomized investigation followed 402 patients who were treated for disc herniation-associated sciatica in private clinics around the state of Maine.  

Two groups were formed: the first consisted of 220 patients who had undergone surgery; the second consisted of 182 patients who had chosen to be conservatively (non-surgically) treated.

The 'bottom-line' of this investigation (which certainly was not without methological flaws) has demonstrated that surgical treatment for disc herniation-associated sciatica is faster and slightly more effective than conservative non-surgical conservative care.

Also noteworthy is the fact that a small sub-group of patients, who existed within the conservatively treated group, fared slightly better than the surgically treated group did. This group was made up of the patients who were the least symptomatic.

Interestingly, the aforementioned results for the Maine Study were amazingly similar to that of the Volvo Award Winning Weber study of 1983.

There are two big problems, however, with this investigation:  #1) there was a disproportional amount of 'litigated' patients (Workers' Compensation) enrolled in the conservative group, i.e., 50% of the non-surgically treated were comprised of patient's in litigation versus 27% in the surgical group; and #2) the criteria for entry into this disc herniation-associated sciatica study was much to loose, i.e., the diagnosis disc herniation-associated sciatica was only based upon the physician's examination findings and did NOT have to be collaborated with MRI, CT, or EMG!

THE RESULTS:

Full Notes on the Five-Year Study:

This was a terribly controlled study!   No MRI or EMG was required to for entry into the study, although 91% of the surgical patients were found to have had a disc herniation or extruded disc fragment.   Another irritating thing was that 50% of the non-surgical group was made of work comp patients on disability versus 27% of the surgically treated patients.   There have been many studies that have demonstrated patients in litigation do NOT respond well to treatment of any kind (for fear of ruining the value of their case).   So, some of the results may be skewed, especially on the conservatively treated side.

This was a huge study that was also known as 'The Maine Lumbar Spine Study'.   It compared 'surgical treatment' to that of 'non-surgical treatment' for patients who suffered from sciatica via suspected lumbar disc herniation.   About 80% (402 patients) of the cohort was available to answer mailed survey questions 5 years after their initial base-line examinations.  

There are two big problems, however, with this investigation:  #1) there was a disproportional amount of 'litigated' patients (Workers' Compensation) enrolled in the conservative group, i.e., 50% of the non-surgically treated were comprised of patient's in litigation versus 27% in the surgical group; and #2) the criteria for entry into this disc herniation-associated sciatica study was much to loose, i.e., the diagnosis disc herniation-associated sciatica was only based upon the physician's examination findings and did NOT have to be collaborated with MRI, CT, or EMG!

This study confirms what others have already found: Sciatica is a nasty disease!   At 5 years only 46% of the non-surgically treated patients reported satisfaction with there condition!   63% of the surgical patients reported satisfaction - a significant difference.   Patient reported "improvement", as compared to their 'base-line' condition, was 70% within the surgically treated group, versus 56% within the non-surgical group.

These result of the Main Study similar to the Weber study (4) that found 'pain improvement' at 70% in surgical patients and only 51% in non-surgical patients after 4 years. (4)

The other significant investigation into the surgical versus non-surgical outcome of disc herniation-associated sciatica was done in 1989 by Nykvist et al. Although this study used surgical techniques over 20 years old, the conservative care methodology is still about the same. Amazingly, 82% of the 'non-operated' patients still suffered sciatica at the 5 year follow-up.   This was based on the following of 97 patients who refused surgery after being hospitalized for sciatica. (6)

RESULTS:

Surgical Failure Rate : The only down fall to surgery was that 19.4% of the surgically treated patients needed a second operation.   These patients had the worse success rates of all. (I would bet there were some stenosis patients mix in here for this is a little higher then other studies found for pure disc herniation surgery.)

'Least symptomatic patients' at base-line' benefited the least from surgery, and did better than the rest of the non-surgical patients (66% versus 46%).   66% reported being satisfied with their outcome at 5 years - which was even better than the surgical group (63%).

Surgery works fast .   At 1 years the surgical group was had reached maximum improvement via the Roland-Morris scores, whereas the non-surgical group took two years! The improvement is much faster following surgery.   After 3 months the non-surgical group 'closes the gap' and almost catches the success of the surgical group but not quite.   This narrowing of the gap, 'stops' after two years (which indicates to me that the non-surgical group will heal for two years.)

They noted that the results may have been on the high side for the 20% drop-out patients were most likely worse than the ones left in the study!

"Surgical treatment remained a significant predictor of improved symptoms and satisfaction even after controlling for baseline differences. work comp patients".   The data clears states that if you have severe symptomatology at base-line and have surgery you have a good chance of doing well - better than most of the less symptomatic 'non-surgical patients'.   The low symptom patients did the best with conservative care - as well and even better than the surgical patients.

"Optimal surgical outcomes can take 3-12 months to achieve".

"Patients reluctant to undergo surgery may elect conservative care, knowing that their symptoms will likely improve, albeit more slowly, and they may remain more symptomatic than those surgically treated."

Full Conclusions:

402 patients (79%) (220 - Surgical, and 182 - non-surgical) were available to answer questions, 5 years after their base-line examination.

• 46% of non-surgical patients were satisfied with their current status.

       63% of the surgical patients were satisfied with their current status.

• 56% of non-surgical reported "improvement" of their pain (back or leg).

       70% of surgical reported "improvement" of their pain (back or leg).

• 38% of non-surgical patients were either much better or completely better.

       57% of surgical patients were either much better or completely better.

Problems:

• 50% of patients in the non-surgical group were work comp on TTD!

       27% of patients in the surgical group were work comp on TTD!

• 41% of non-surgical's were scanned.

       55% of surgicals were scanned.

At 5 Years Summary:

63% of surgical patients were "satisfied" (delighted, pleased, mostly satisfied)

46% of non-surgical patients were "satisfied" with their outcome.

91% of surgical patients were working.  

84% of non-surgical patients were working.

28% of surgical patient's pain was completely gone.

12% of non-surgical patient's pain was completely gone.

82% would choose surgery again.

There was no difference in the percentage of patients back at work! (% not given)

19.2 % of the surgical patients (most of which had a discectomy - 96%) had to have another operation!   (92% had HNP or sequestration at surgery)

References:

(5) Atlas SJ, Deyo RA, et al. 'Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study.' Spine. 2005 Apr 15;30(8):927-35

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