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Surgery for Herniated Lumbar Disc and for Spondylolisthesis

Two studies address the benefits — or lack thereof — of surgery for degenerative lumbar spine disease.

These two studies address the use of surgery for different types of degenerative lumbar spine disease.

Peul and colleagues randomized 283 patients with lumbosacral radicular pain to either microdiskectomy or conservative treatment; incapacitating lumbosacral radicular pain had lasted 6 to 12 weeks and was due to lumbar disc herniation. In the conservative-treatment group, surgery was offered after 6 months to patients with persistent sciatica and before 6 months to patients with nonresponsive leg pain or progressive neurologic deficits.

Of the 141 patients randomized to early surgery, 16 recovered before surgery could be performed; the remainder underwent surgery with a median delay of 1.9 weeks. Of 142 patients randomized to conservative treatment, 55 crossed over and had surgery during the first year (median of 14.6 weeks to surgery). For the first 4 weeks after surgery, the conservatively treated group did better, but after 4 weeks the operative group had less pain than the conservative-treatment group. The greatest difference in pain outcome between the groups (favoring the early-surgery group) occurred between 8 and 12 weeks. In the early-surgery group, 3.2% of patients had a second operation because of recurrent sciatica, compared with a 1.8% reoperation rate among the conservative-group patients who underwent surgery. At 1 year, the groups did not differ significantly on any outcome measure. The major advantage of early surgery was faster relief of sciatica pain.

Weinstein and colleagues enrolled 304 patients with degenerative lumbar spondylolisthesis in a randomized intention-to-treat study (surgery vs. conservative treatment) and 303 patients in an observational cohort study. However, the 1-year crossover rate in the randomized group was about 40% in each direction, so the authors lumped the two study cohorts together as observational and compared all results based on treatment actually received. A total of 372 patients had surgery within the first 2 years, and 235 were treated conservatively. The complication rate of surgery was reported only as "89% of the surgical patients had no operative complications." Compared with conservatively treated patients, those who underwent surgery had statistically significantly better pain outcomes at 3 months and an even greater benefit at 1 year that diminished only slightly at 2 years.

Comment: Microdiskectomy is a valid early treatment for severe sciatica due to lumbar disk herniation, but patients must be informed that, provided no severe complications of disk herniation occur, the end result will be the same with or without surgery. The findings of Peul and colleagues confirm previous conclusions (Spine 1983; 8:131). Any decision in favor of surgery is therefore elective and patient-driven, with the motive of symptom relief.

The findings of Weinstein and colleagues favor surgery for spondylolisthesis, but the study was not really controlled. The conclusion sounds intuitively correct in that the defect is structural and bony. Although symptoms may fluctuate or even be absent, if there is functional impairment it makes sense to correct the basic pathology, which will not resolve spontaneously as disk herniations can.

— Michael Ronthal, MD

Dr. Ronthal is Professor of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston.

Published in Journal Watch Neurology July 17, 2007

Citation(s):

Peul WC et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007 May 31; 356:2245-56.

• Original article (Subscription may be required)
• Medline abstract (Free)

Weinstein JN et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007 May 31; 356:2257-70.

• Original article (Subscription may be required)
• Medline abstract (Free)

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• Diskectomy
  Bm Metcalf, Mattix Cabinet Works, 8 May 2009 11:25 AM EST
  I had a diskectomy approx. 9 months ago on the L5-S1. I had severe right leg pani on my right... [more]