October 1, 2014
For those people suffering with disc herniations, the decision regarding surgery versus no surgery is often a very difficult and confusing one. Spinal surgeons will argue that surgery is the way to go, while osteopaths and physios may suggest otherwise. In this blog I will objectively outline some of the stats relevant to this topic in an attempt to help both those wrestling with the decision and practitioners who may want more information in order to appropriately advise patients.
Let’s have a look at some relevant studies through the years;
1983 – Weber:
Weber looked at 126 patients with confirmed herniated discs on MRI. One group received surgery, while the other group received conservative non-surgical care. The groups were then examined at 1, 4 and 10 years after treatment.
After 1 year, the surgery group was doing better. At 4 and 10 years, there was no significant difference between the two groups.
1999 – Loupasis et al:
Loupasis followed 109 patients post discectomy (surgical removal of disc material) at an average follow up of 12 years after surgery. Satisfactory results were found in 64% of patients, 28% still complained of significant back or leg pain, 7% had repeat operations.
2006 – Weinstien et al:
501 patients studied, looking at the difference between surgery and non-surgery patients after a 2 year period post treatment. No significant differences could be found between the two groups.
2008 – Peul et al:
283 patients studied, 141 underwent “early” surgery i.e. within 6-12 weeks of symptom onset. 142 were consigned to conservative treatment for 6 months. Early surgery gave more rapid relief of sciatic pain versus the non surgical group, however, outcomes were very similar after one and two years post treatment.
To summarise, these studies show that surgery can be more effective than non surgical care in the short term, however, long term prognosis for surgery and non surgical intervention is very similar.
What happens to the disc material if it is not surgically removed?
Numerous studies have been done that have looked at non surgical patients with disc herniations over various periods of time. These studies have demonstrated that disc herniations can decrease in size substantially over a period of months without surgical intervention. Mother Nature is indeed a very powerful healer. It is also worth noting that many people are walking around with disc abnormalities and are completely pain free. 64% of pain free patients when studied on MRI were found to have disc abnormalities in a study conducted by Jensen et al (1994). You could argue, therefore, that the body has the capacity to cope with disc abnormalities and patients, by seeking non surgical care, can be helped to identify the appropriate movements, positions and postures which will allow for this.
Nikolai Bogduk, a leading voice on the aetiology of back pain, identifies that many structures in the back can cause referred pain into the lower limb. It may be the case, therefore, that the pain in your back and leg is in fact a multi-tissue event and removing the disc alone from this equation may not necessarily be the answer.
Conversely, however, you could argue that if the outcome of surgery versus non-surgical intervention is the same after 1 to 2 years, yet surgery offers quicker relief, then surely surgery sounds like the better option. And for some people it may well be. Microdiscectomy techniques now offer a neater and comparatively less invasive procedure than previous techniques. One should still consider, however, the tissue damage, scarring and reduced movement potential caused by surgery and how this may affect your ability to make a full, long term recovery.
Weber, H. 1983. Lumbar disc herniation. A controlled prospective study with ten year observation. Spine 8:131-140
Loupasis, G. A. Et al. 1999. 7 to 20 year outcome of lumber discectomy. Spine 24:2313 – 2317
Weinstien , J. N. Et al. 2006. Surgical vs nonoperative treatment for lumber disc herniation, Journal American Medical Association.
Peul, W. C. Et al. 2009. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation. BMJ, vol 336.
Jensen, M. C. Et al. 1994. MRI of the lumbar spine in people without back pain. New England Journal of Medicine.