Latest Summary of Treatment for Lumbar Disk Herniation
Every now and then it's a good idea to step back and review a problem like lumbar disc herniation. What does the latest research say works best? Are there any changes in the guidelines or recommendations for the treatment of this problem?
In this article, Dr. R. W. Molinari from the Division of Spinal Surgery at the University of Rochester in New York summarizes all the important published studies on this topic over the past year. Both conservative (nonoperative) care and surgical management are included.
This information is especially important these days because lumbar discectomy (removal of a herniated disc) is the most common surgery performed in the United States for back and leg symptoms. There has been a trend toward microdiscectomy. Microdiscectomy is the removal of disc or disc fragments through an endoscope without an open incision or invasive procedures.
The effectiveness of this treatment is now being reported. Groups of patients with lumbar disc herniation treated with nonsurgical care have been compared to patients who had a microdiscectomy. When it came to pain intensity, disability, and quality of life, the results were no different between the two groups. However, the discectomy groups did have a faster recovery.
One study to keep in mind is the Spine Patient Outcomes Research Trial (SPORT). This study has patients enrolled from 13 different multidisciplinary spine clinics. Over 500 patients with lumbar disc herniation were included. All had symptoms of back and leg pain for at least six weeks.
In the SPORT study, outcomes between standard open discectomy and nonsurgical treatment were measured at regular intervals up to two years after treatment. Patients in both groups had good results. But critics of the study point out that at the end of two years, 40 per cent of the patients who were in the surgery group decided to try conservative care instead. And 40 per cent of the conservative care group crossed over to the surgical group and did have surgery. Results may be skewed by this crossover rate.
Based on research thus far, overall recommendations for surgery are as follows:
Surgery should always be done AFTER an adequate trial of nonoperative treatment. This
should include nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, and rest or activity modification.
Surgeons can advise patients that surgery will likely reduce painful symptoms, thus
restoring motion and function.
Surgery is an immediate priority if there is cauda equina syndrome (numbness in
the groin area, bowel and bladder problems); this is an indication of pressure on multiple lumbosacral nerve roots.
Surgery is advised when there is severe, constant pain.
There are enough studies now to compare the results of open discectomy versus microendoscopic discectomy (MED). Pain improvement is the same between these two surgical techniques. As might be expected, length of hospitalization and amount of blood loss were less with the minimally invasive MED. Problems after either surgery were low. Patients in the MED group were able to return to work much faster.
Smaller studies of MED with obese patients also report good results. Complication rates are low making this a good choice for this group of patients. The use of steroid injections is on the rise for this condition. But there's no evidence to support this treatment. Success rates vary from 18 to 90 per cent for lumbosacral injections. More study is needed to find out why results vary so much and determine ways to improve results for all patients.
Younger patients may be treated with lumbar disc chemonucleolysis. This is the dissolving of the disc using an injection of an enzyme such as chymopapain. It is used most effectively when the disc has protruded but is still contained within its outer covering. Chemonucleolysis works well to bridge the gap between conservative (nonoperative) care and surgery. And having this procedure doesn't prevent the patient from having surgery if it is needed later.
Physical therapy (PT) is often recommended after lumbar disc surgery. There aren't many studies on the effectiveness of PT. One study of 120 patients compared comprehensive PT to sham neck massage, or no therapy at all. At the end of three months, the PT group had the best short-term results. However, there wasn't much difference between comprehensive PT and the sham neck massage. This suggests that the benefits of hands-on care may be more psychologic than physical.
It's in everyone's best interests to continue studying the safest and most effective way to treat lumbar disc herniation. Finding the most effective treatment for lumbar disc herniation can lower medical costs, reduce pain and disability, and improve quality of life.
Robert W. Molinari, MD. Lumbar Disk Herniation: Treatment Strategies for Primary and Recurrent Lumbar Radiculopathy. In Current Orthopaedic Practice. July/August 2008. Vol. 19. No. 4. Pp. 346-350.