Factors Associated with Progression to Surgical Intervention for Lumbar Disc Herniation in the Military Health System.

Retrospective Cohort OBJECTIVE.: To determine surgery-free survival of patients receiving conservative management of LDH in the military health system (MHS) and risk factors for surgical intervention.
Radiculopathy from lumbar disc herniation (LDH) is a major cause of morbidity and cost.
The Military Data Repository (MDR) was queried for all patients diagnosed with LDH from FY2011-2018; the earliest such diagnosis in a military treatment facility was kept for each patient as the initial diagnosis. Follow-up time to surgical intervention was defined as the time from diagnosis to first encounter for lumbar microdiscectomy or lumbar decompression in either a military treatment facility or in the civilian sector. The MDR was also queried for history of tobacco use at any time during MHS care, age at the time of diagnosis, sex, MHS beneficiary category, and diagnosing facility characteristics. Multivariable Cox proportional hazards models were used to evaluate the associations of patient and diagnosing facility characteristics with time to surgical intervention.
84,985 MHS beneficiaries including 62,771 active duty service members were diagnosed with LDH in a military treatment facility during the eight year study period. 10,532 (12.4%) MHS beneficiaries, including 7,650 (10.9%) active duty, failed conservative management onto surgical intervention with lumbar microdiscectomy or lumbar decompression. Median follow up time of the cohort was 5.2 (IQR 2.6, 7.5) years. Among all healthcare beneficiaries, several patient-level (younger age, male sex and history of tobacco use) and facility-level characteristics (hospital vs. clinic; and surgical care vs primary care clinic) were independently associated with higher risk of surgical intervention.
LDH compromises military readiness and negatively impacts healthcare costs. MHS beneficiaries with LDH have a good prognosis with approximately 88% of patients successfully completing conservative management. However, strategies to improve outcomes of conservative management in LDH should address risks associated with both patient and facility characteristics.
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