Research Review of Treatment of Bulging Disc

Gugliotta M, da Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016;6(12):e012938. Published 2016 Dec 21. doi:10.1136/bmjopen-2016-012938

Reviewed by Dr. Tanner Tunsky

Summarized Review Conclusions

Surgery vs. conservative treatment of disc bulges has been a discussion amongst healthcare professionals for a while now. This study reviewed clinical outcomes of patients who chose to treat disc bulges conservatively with exercise and time, compared to those who chose to treat the disc bulges with surgery. While outcomes in the short term favor the surgical route, there was no difference in clinical outcome in the long term when comparing the two methods of treatment.

“Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (−0.97; 95% CI −1.89 to −0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (−3.7; 95% CI −7.4 to −0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.”

“There was little evidence of a difference in quality of life between groups throughout the study. Patients in the surgical group tended to score better on the SF-36 physical subscale in the short term (6 weeks: −3.1, 95% CI −6.4 to 0.1), but the difference was minimal in the long term (2 years: −0.6, 95% CI −4.7 to 3.5). Scores of the SF-36 mental subscale were similar in both groups in all follow-up assessments.”

“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.”

Introduction to the Research

This research was done to determine if surgery is in fact a more effective route to manage disc bulges in the lumbar spine. Surgery was compared to more conservative treatment that included physical therapy, ergonomics, and at home exercise. The two groups and their outcome measures were compared at various times in their recovery, ranging from 6 weeks to 2 years.

Research Methodology

The assignment to treatment interventions was decided by physicians based on patients’ clinical indications. Surgical treatment was a standard open discectomy as described by Delamarter and McCulloch and by Spengler, with examination of the involved nerve root performed using a microscope, with the patient under general anaesthesia and in the knee–chest position. After a midline incision, the paraspinous muscles were reflected and the interlaminar space was entered. If necessary, the medial border of the superior facet was removed to provide an unobstructed view of the involved nerve root. Using a small annular incision, the herniated disc fragment was removed, the spinal canal was inspected and the foramen and recessus probed for residual disk or bony pathology. The nerve root was then decompressed, with the purpose of leaving it freely mobile.

The conservative treatment consisted of ergonomic instruction, active physical therapy, education/counselling with instructions for home-based exercise, and non-steroidal anti-inflammatory drugs if tolerated. Patients with insufficient analgesic response were prescribed additional opioids. Those with an inadequate response to opioids were offered epidural infiltrations, CT-guided periradicular infiltrations and, in the case of continued inadequate response or recurrence, CT-guided pulsed radiofrequency therapy of the affected nerve root. If conservative treatment failed, which was ascertained on a case-by-case basis, surgery was provided as an option

Research Findings

Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (−0.97; 95% CI −1.89 to −0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (−3.7; 95% CI −7.4 to −0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.

Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.

Research References

As always with these reviews, these are my takeaways from the article and I encourage you to read the article in its entirety. The references used in this article by the authors of this article are listed here.

Our Message

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