Longer duration of disc herniation symptoms equates with worse post-treatment results

SF-36 scores after surgical or nonsurgical management changed most favorably from baseline in patients with 6 or fewer months of lumbar herniation symptoms.

Issue: September 2010

Mark F. Kurd

Investigators studying patients in the Spine Patients Outcomes Research Trial with lumbar disc herniations found that those treated soon after the onset of their symptoms had the best outcomes, based on the study’s primary outcome measures.

The study, conducted by several U.S. researchers, analyzed the results of 1,192 patients with intervertebral lumbar disc herniations (DH) enrolled in either the randomized or observational arms of the Spine Patient Outcome Research Trial (SPORT). Prior to treatment, lumbar DH symptoms lasted less than or equal to 6 months in 927 patients, and for more than 6 months in 265 patients.

Mark F. Kurd, MD, of Philadelphia, presented the findings at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). “Patients with greater than 6 months of symptoms certainly had worse outcomes whether treated operatively or nonoperatively. When evaluating the treatment effect, the benefit of surgery relative to nonoperative management was independent of the duration of symptoms,” he said.

Both groups had regular post-treatment evaluations for 4 years.

SF-36 bodily pain results

In the surgical group, the SF-36 bodily pain score, one of three primary outcome measures used in the SPORT study, changed from baseline by 48.3 points for patients with a lesser duration of symptoms compared to 41.9 points for those with a greater duration of symptoms. This trend also occurred with the other two primary outcomes measures: the SF-36 physical function and Oswestry Disability Index (ODI) scores, he said.

“These findings persisted throughout the 4-year period,” he noted.

Findings were similar in the nonsurgical group. “In the primary outcome measures, patients in the early treatment group had significantly better outcomes than those in the late treatment group,” Kurd said.

No treatment effect noted

Kurd and colleagues also studied the treatment effect, which they defined as the change from baseline in the surgical group compared to the nonsurgical group.

“When comparing the treatment effect across all three primary outcome measures, there was no significant difference between patients treated early or late,” Kurd said, noting that this suggests the benefits of surgery are independent of symptom duration.

Co-investigator Jeffrey A. Rihn, MD, assistant professor, Department of Orthopaedic Surgery, Thomas Jefferson University and the Rothman Institute, in Philadelphia, stated in an AAOS press release, “[The] bottom line is patients who seek treatment, whether it is surgical or non-surgical during the first 6 months of symptoms will respond better to treatment. We also learned that surgery offers advantages over non-surgical treatment regardless of the duration of symptoms.”

Investigators also analyzed the back pain and leg pain bothersomeness results — two of the secondary outcomes used — however changes in those measures did not reach statistical significance, Kurd noted. – by Susan M. Rapp

Reference:

Rihn J, Hilibrand AS, Blood E, et al. Does the duration of symptoms affect outcomes in the treatment of lumbar disc herniation? Paper 61. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13. New Orleans.

Mark F. Kurd, MD, can be reached at Jefferson University Hospital, 1015 Walnut St., Suite 801, Philadelphia, PA 19107; 215-955-1500; e-mail: mark.kurd@gmail.com.

Steven R. Garfin

These data are consistent with older studies in the literature (from multiple Scandinavian researchers). It describes again the 6-month window after which clinical results from surgery (as well as nonoperative care) are not as reliable as decompression done earlier. This message needs to be understood by not just patients, but physicians, particularly those in the nonoperative area treating patients’ sciatica from herniated discs. As shown here, there is a point from onset of symptoms (within 6 months) where it is best, if surgery is contemplated, to perform the decompression rather than to persist with nonoperative care waiting for improvement, that may be slow (if at all) to come. In some cases too much and too long nonoperative care is not conservative.

– Steven R. Garfin, MD
Orthopedics Today Editorial Board member
Professor and Chair, Department of Orthopaedics University of California San Diego
San Diego, Calif.

Follow OrthoSuperSite.com on Twitter