Surgical versus conservative treatment for lumbar disc herniation a prospective cohort study Europe PMC Article Europe PMC radiografia columna lumbar

We included in the present study consecutively sampled patients from a routine clinical practice registry who were followed-up until 2 years after treatment. Thus, as opposed to randomised controlled trials of head-to-head comparisons between surgical and conservative treatment for lumbar disc herniation, which are hampered by a large number of crossovers and dropouts, our results are directly generalised to routine clinical settings.

Sciatica is one of the most debilitating types of pain emanating from the low back, with a lifetime incidence of ~30%. 1 2 sciatica is a disorder caused by pressure on or irritation of the nerve root. Main symptoms and signs include unilateral leg pain that is worse than concomitant low back pain, pain radiating beyond the knee, decreased muscle strength in a myotomal distribution and sensory deficits in a dermatomal distribution. 3 4 compared with patients with localised low back pain only, those with sciatica generally have more persistent and severe pain, worse prognosis, consume more healthcare resources and are disabled and absent from work for a longer period of time. 1

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Lumbar disc herniation is considered to be one of the main causes of sciatica, and lumbar discectomy is the most popular surgical procedure performed in patients with sciatica in the USA. 1 2 5–7 lumbar disc herniation also occurs in asymptomatic patients, and often spontaneously regresses without surgery. 8–10 conservative treatment, including physical therapy, pharmacological treatment and infiltrations, is an alternative approach for symptomatic patients; 90% of sciatica cases due to lumbar disc herniation resolve with conservative measures. 5 9 conservative treatment of lumbar disc herniation has a lower risk of complications than surgery and is preferred by the vast majority of patients. 11

Several studies have compared the effectiveness of surgical and conservative treatment in patients with lumbar disc herniation associated with sciatica, but methodological aspects limit interpretation of their results.Radiografia columna lumbar observational cohort studies have typically differed in important baseline prognostic indicators between treatment group and their results were thus more prone to confounding. 12–14 randomised controlled trials (rcts) are less prone to generate confounded results. However, in rcts comparing surgical with conservative treatment, a large proportion of patients randomly allocated to conservative treatment actually received surgical treatment right after randomisation or after an initial period of conservative treatment (26–54%). 7 15–17 therefore, rcts are actually mainly comparing early surgery with conservative treatment and delayed surgery in selected patients, as was referred to by peul et al. 18 19 in addition, some researchers have questioned whether patients willing to participate in rcts of surgery versus conservative treatment are representative of patients commonly seen in clinical practice. 20–23

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In order to present results that are more representative of routine clinical care while minimising the risk of confounded results, we conducted a properly sized observational cohort study in a routine clinical setting using consecutive sampling, in which baseline differences in prognostic indicators were accounted for in an analysis with inverse probability weighting closely mimicking an RCT, with the aim of comparing the effect of surgical and conservative treatment on sciatica symptom severity and quality of life in patients with lumbar disc herniation.

Baseline and efficacy data are presented as counts and percentages for dichotomous variables and as means and sds for continuous variables. Between-group comparisons of baseline data were performed using pearson’s χ 2 for dichotomous variables and student’s t-test for continuous variables.Radiografia columna lumbar only patients with complete primary outcome data, that is, NASS back pain assessed at 6 or 12-week follow-up, were considered in the analysis. We accounted for missing data by using multiple imputation with baseline efficacy variables, age, body mass index, gender, social status, employment status, country of origin and treatment group as explanatory variables in the imputation model, to create 20 imputed data sets. For each patient, we estimated propensity scores for receiving surgical treatment using a probit model that included baseline efficacy variables, age, body mass index, gender, social status, employment status and country of origin as explanatory variables. Propensity scores were then used to derive inverse probability of treatment weights, with the inverse of the propensity score as analytic weights for patients in the surgical group and the inverse of 1 minus the propensity score for patients in the conservative group. 33 34 to account for repeated measures within patients across multiple follow-up assessments, we used linear or logistic mixed-effects models adjusted for the inverse probability of treatment weighting to derive, for each outcome measure at each follow-up time, group-specific means or proportions with 95% cis and between-group differences in means or proportions with 95% CI.Radiografia columna lumbar statistical analyses were performed with STATA release 12.1 (stata corp, college station, texas, USA). All p values are two-sided.

We found no evidence that surgical treatment, when compared with conservative treatment, reduced the severity of sciatica symptoms or improved the quality of life of patients with lumber disc herniation in the medium or long term. Pain was relieved more quickly in patients who received surgical treatment (evident at the 3-week follow-up), but the difference between groups was no longer present after 3 months. Patients in the surgical group did report less physical impairment at the 1-year follow-up, but not in previous or subsequent assessments. Surgery was not more effective for the treatment of neurogenic symptoms or the improvement of quality of life over the course of the study.Radiografia columna lumbar

Faster improvement in pain symptoms with surgical treatment is a common finding in comparisons with conservative treatment in patients with lumbar disc herniation. Previous observational studies have also found that back pain is reduced more quickly with surgical treatment. 12–14 35 findings regarding neurogenic symptoms, physical function, and quality of life, however, are not as consistently reported by other observational studies. As opposed to our findings, previous observational studies have found benefits of surgical treatment in these outcomes at short-term and long-term follow-up. The discrepancy between our findings and those of previous studies may be due to differences in eligibility criteria and methods of outcome assessment, a more effective control intervention and a different approach to statistical analysis to control for confounding by indication.Radiografia columna lumbar

Interestingly, results of our observational cohort conducted in a routine care setting more closely resemble those reported by previous rcts. 7 15–19 rcts have also typically reported quicker pain reduction in patients who received surgery, but no clear benefit of surgery over conservative treatment at long-term assessments of neurogenic symptoms, physical function or quality of life. However, in the classic trial by weber, 15 the beneficial effect of surgical treatment lasted longer than in other trials; treatment effects of surgical and conservative treatment only became similar after 4 years of follow-up, and remained similar until the 10-year final follow-up.

The observational nature of our investigation limits our ability to interpret its findings.Radiografia columna lumbar in observational clinical studies, results are likely to be influenced by confounding by indication. Patients with a worse prognosis at baseline are more likely to be allocated by physicians to surgical intervention, and indeed, this was the case in our study, in which patients in the surgical group showed a trend towards worse neurogenic symptoms at baseline (p=0.098). However, the methods we used for statistical analysis allowed us to mimic a randomised controlled experiment. 29 this method of analysis, that is, inverse probability weighting, assumes that the probability of being allocated to surgical or conservative treatment depends mainly on the prognostic indicators we included in our analysis. Although this assumption may be inaccurate in some cases, our results are remarkably similar to those reported in previous rcts.Radiografia columna lumbar surgical rcts are commonly criticised for lack of generalisability because patients who agree to be randomised in these trials may not be representative of those seen in clinical practice. The results of the present investigation do not suffer from this limitation, because no randomisation took place. Moreover, a significant number of patients dropped out of our study due to loss to follow-up, especially by latter time points. We conducted multiple imputation as an attempt to include in our analysis patients with missing outcome data; however, no statistical technique is likely to completely solve the problem of missing data, and it is always better to have observed data as opposed to imputed data for all patients included in the analysis.

Surgical and conservative treatments had long-term beneficial effects on sciatica symptoms in patients with lumbar disc herniation.Radiografia columna lumbar compared with conservative treatment, surgical treatment relieved back pain faster, but no relevant clinical difference was observed after 3 months. Surgical treatment may thus be attractive to patients with debilitating pain symptoms who seek quick relief, or who did not experience satisfactory improvement with conservative treatment.

Contributors: PH, HL, RT and MG conceived and designed the experiments; MG, ED, RT, HL and PH performed the experiments; brdc, PJ and SR analysed the data; MG, ED, RT, HL, PH, brdc, PJ and SR contributed to the writing of the manuscript.

Competing interests: PJ has received research grants to the institution from astra zeneca, biotronik, biosensors international, eli lilly and the medicines company, and serves as unpaid member of the steering group of trials funded by astra zeneca, biotronik, biosensors, st jude medical and the medicines company.Radiografia columna lumbar the other authors report no conflict of interest.