Surgery found to speed relief from slipped disks
Back patients with sciatica caused by a slipped disk do very well after two years whether they have surgery or undergo nonsurgical treatment, a major study has found, though surgical patients tend to gain relief sooner.
Supported by the National Institutes of Health, the research was intended to help settle a long-standing controversy over the effectiveness of spinal surgery to repair a slipped disk compared with conservative therapy that includes exercises and anti-inflammatory drugs.
But the results, reported in today’s issue of the Journal of the American Medical Assn., were somewhat inconclusive, primarily because attempts to randomly assign patients into two groups broke down. Of the 232 patients who were to have disk surgery, 40% changed their mind and opted for nonsurgical therapy, while 45% of the 240 patients assigned to nonsurgical care decided to have surgery. The study was conducted in 13 spine clinics in 11 states.
“We can’t say which treatment is better,” said Dr. David Flum of the University of Washington School of Medicine, who commented on the study in a journal editorial. “We can say that people who choose their intervention seemed to be choosing wisely because both groups got better.
“Of course it remains to be seen whether or not the people who chose surgery, had they not chosen surgery, would they have done just as well? That’s really the question that everybody wants to know.”
Despite the crossover problem, the study yielded several important findings, said the study’s lead author, Dr. James Weinstein of Dartmouth Medical School.
“This study for the first time showed very significant improvement in the patients who ended up with nonoperative treatment,” he said. “On the other hand, if they had to engage in a surgical option, they also did quite well and there weren’t a lot of side effects. We also learned that patients don’t get a lot worse in either treatment.”
The spine’s vertebrae are separated and cushioned by disks that are made of cartilage. When these disks rupture, usually through wear and tear, they can bulge inward, pressing on nerves in the spinal column, causing pain or partial weakness.
An estimated 12 million Americans suffer from degenerative disk disease. Of the more than 1 million who undergo surgery to repair herniated disks each year, about 25% suffer from sciatica, a burning pain in the leg. Surgery costs approximately $10,000 and can be done on an outpatient basis.
Trying to find an answer to the surgery-vs.-nonsurgery question for herniated disks is important, Weinstein said, because the number of spinal operations has been increasing, and the rate of these surgeries can vary greatly around the country.
The study found that surgery quickly relieves disabling symptoms in patients with sciatica when compared with nonsurgical care. Surgery patients were often able to resume normal activities in a matter of weeks, while those not being operated on usually took several months or more to feel as good. But after two years, both groups appeared to do equally well.
That means that sciatica “will eventually get better in most people, but it can take a long, long time,” said Dr. Eugene Carragee of Stanford University Medical Center, who wrote an accompanying editorial. “By six weeks after surgery, those people are very close to normal in pain, function and other parameters.”
The study also found that severely damaged disks do not appear to pose a risk of paralysis or other catastrophic event if they are not surgically corrected. Many surgeons advise surgery out of concern that sudden twisting might further damage a ruptured disk.
For patients whose sciatica causes intolerable pain, surgery will make them feel better quickly, Carragee said. And people who want to avoid surgery can do so knowing there is little risk of making the problem worse, he said.
