A lumbar disc herniation occurs when part of the jellylike material in the center of a disc between two vertebrae in the lower back forces its way through a weakened area of the disc and pushes on a nerve. Patients with lumbar disc herniation usually experience significant back pain and radiating leg pain, numbness, and even weakness. Studies have shown that symptomatic lumbar disc herniation affects 1% to 2% of Americans at some point in their lives, most often in their 30s or 40s.
Typically, symptoms of lumbar disc herniation improve within 6 to 8 weeks. Treatments usually involve nonsurgical approaches at first, such as medications, patient education and counseling, and physical therapy. Current guidelines recommend that surgery be considered only for patients who experience pain beyond a reasonable course of non-operative therapy. Others who may be considered for surgery on a more emergent basis include those who have progressive muscle weakness in the legs, or loss of bladder or bowel control from nerve compression.
Symptom Duration in Disc Herniation
In a study published in the October 19, 2011 Journal of Bone and Joint Surgery, my colleagues and I observed 1,192 patients enrolled in the Spine Patient Outcomes Research Trial, which was conducted at 13 spinal practices in 11 states. Patients were aged 18 or older and suffered from various symptoms of lumbar disc herniation. They were assigned to undergo either operative treatment or non-operative treatment. At different intervals after receiving treatment, we compared outcomes of patients who had symptoms for 6 months or less to those who had symptoms lasting longer than 6 months prior to enrollment in the study.
“Outcomes were significantly worse in patients who had symptoms for more than 6 months prior to treatment.”
Patients with herniated lumbar disc symptoms faired significantly worse if they had symptoms for more than 6 months prior to treatment, compared with those who had symptoms for 6 months or less. Outcome measures included:
At all follow-up intervals, outcomes were significantly worse in patients who had symptoms for more than 6 months prior to treatment than in those who had symptoms for 6 months or less. The analysis also revealed that operative treatment was significantly more effective than non-operative treatment. However, the increased benefit of surgery over nonoperative treatment did not depend on the duration of symptoms. Patients who had symptoms for longer than 6 months still found relief with either non-operative treatment or surgery, but some did not reap as much benefit as those who had symptoms for 6 months or less.
Important Implications of Lumbar Discectomy
Lumbar discectomy is one of the most effective spinal surgical procedures, but there is currently no consensus on the timing of surgery. Various studies suggest waiting anywhere from what has been referred to as “an appropriate amount of time” to 12 months after symptoms begin. Many patients will ask if the duration of their symptoms will affect their potential for a full recovery. Our study sheds some light on when surgery should be considered based on symptom duration. The findings can be used to help guide clinical decision making with patients.
Readings & Resources (click to view)
Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes. Analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am. 2011;93:1906-1914. Available at: http://www.jbjs.org/article.aspx?articleid=179649.
Rhee JM, Schaufele M, Abdu WA. Radiculopathy and the herniated lumbar disc. Controversies regarding pathophysiology and management. J Bone Joint Surg Am. 2006;88:2070-80.
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006;296:2451-2459.
Tosteson AN, Skinner JS, Tosteson TD, et al. The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine. 2008;33:2108-2115.
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009;91:1295-1304.