June 2007 | Back to Table of Contents
Quality Rounds
Opt for Surgery or Wait It Out?
By Scott D. Smith
For patients with a herniated disk, deciding on treatment may boil down to one question: How long can you stand the pain?
In 1997, Monty Seper, M.D., felt a sharp stab of pain travel down his leg after playing recreational hockey. At the time, he was a 30-year-old family physician working in Churchill, Manitoba—a town at the edge of the Arctic Circle that bills itself as the “Polar Bear Capitol of the World” because 1,200 or so pass by each fall.
As he left the dressing room, his foot dropped—the classic symptom of a herniated disk with radiculopathy. Seper walked with a clump and was bent over in pain before flying to Winnipeg a few days later to visit a neurologist, who confirmed the diagnosis, as did imaging six weeks later.
The neurologist recommended surgery. But Seper, thinking back surgery was for older men who weren’t as physically active, wasn’t interested. “I was thinking, I have my whole life ahead of me, and here I’m having back surgery,” he says.
Instead, he decided to visit a physical therapist and work on strengthening his foot and his back muscles. The first six weeks were the hardest and most painful, he says. But he saw improvement and was encouraged enough to stick with the program.
Today, Seper has a strong, pain-free back, and he coaches youth hockey and runs marathons. He also treats patients with back problems at Physicians Neck & Back Clinics in Lakeville.
His experience illustrates the tough choice patients must make when they’re suffering from pain caused by a herniated disk. Until recently, there was little data to guide them as they decided whether or not to have surgery.
But recently published studies may be changing that. James Weinstein, D.O., of Dartmouth Medical School and other researchers did the first large-scale study comparing the effectiveness of disk surgery and conservative treatment.
The $15 million effort, called the Spine Patient Outcomes Research Trial (SPORT), included a randomized trial involving 501 people and an observational cohort involving 743 people. In the randomized trial, half the participants were to undergo surgery and half were to receive nonoperative care. Articles about the studies were published in the November 22-29, 2006, issue of the Journal of the American Medical Association.
Taken together, the studies show that patients who had surgery and those who didn’t both improved substantially over time.
“When I saw this study, I thought, ‘This is what I’ve been telling patients for years,’ but someone finally got the numbers together,” Seper says.
Just what those numbers mean is open to some interpretation.
Results from the randomized trial showed that patients in each group improved over a two-year period. However, investigators were unable to say that one treatment was superior because about half the participants assigned to have surgery never had it and about 30 percent of those who were assigned to the conservative care group ended up having surgery during the study period.
Results from the observational cohort suggested that those who chose surgery reported greater improvement than those who elected nonoperative care. At three months, patients who chose surgery made bigger gains on measures of pain and physical functioning that included ability to work, satisfaction with symptom relief, and self-rated improvement. But those differences narrowed at two years, and the authors noted that the comparisons were based on nonrandomized trials and self-reports, rather than objective evidence.
What Does It Mean?
Lumbar diskectomy, which involves removing part of the disk to take pressure off the nerve, had been perceived as the more effective treatment for patients with an imaging-confirmed herniated disk and leg pain for more than six weeks. Physicians also believed that waiting to have the surgery might cause more nerve damage.
But the studies seemed to show that while surgery appeared to alleviate pain more quickly than conservative care, which includes treatments such as physical therapy, epidural injections, chiropractic manipulation, anti-inflammatories, and opioid analgesics, both worked in the long run.
David Polly, M.D., chief of spine surgery at the University of Minnesota, who was not involved in the study, says the findings confirmed the conventional wisdom that surgery is an effective treatment for the condition. “Surgery works pretty well,” he says. “At two years, the results were pretty similar for those who had surgery and those who didn’t, but before the two years, those who had surgery had significantly less pain.”
He also was not surprised that conservative care does work over time and that pursuing it didn’t harm patients. He tells patients, “If you can live with this pain, you will get better. If you can’t, then we have an operation that lasts about an hour and a half.”
Whether the person has a physical job, such as doing carpentry or playing professional sports (NFL quarterback Joe Montana had a diskectomy in 1986 and went on to win that season’s Super Bowl), also may affect their decision to opt for surgery.
For example, a fellow orthopedic surgeon came to Polly seeking treatment for his herniated disk. After Polly presented both options, the surgeon opted for surgery in order to get back to work as soon as possible. Seper tells patients his story and also tells them that surgery can relieve their pain. But he warns that it might not fix the weak back and abdominal muscles that may have contributed to the herniated disk in the first place.
“It’s a lot harder for people to buy into conservative treatment because it requires commitment from them,” he says. “Everyone is looking for the quick fix, but I tell them that sometimes the quick fix isn’t the best fix.”
Since patients have two valid options, physicians must educate them and help them decide which course of treatment is best, says Thomas Marr, M.D., medical director of HealthPartners, who helped design the organization’s disease-management strategy for back pain. “If the internist says ‘I’m not going to refer you to a surgeon, this is going to go away by itself,’ or if the surgeon says ‘Surgery is the only treatment,’ then we’re not benefiting the patient,” he says.
Jeffrey Dick, M.D., an orthopedic spine surgeon at Twin Cities Orthopedics, says the high rate of crossover between treatment groups in the SPORT study also shows the importance of allowing patients and physicians to make treatment decisions on a case-by-case basis instead of in accordance with rigid guidelines.
Dick says in his practice, the majority of patients who have surgery found conservative treatments didn’t do enough to control their symptoms. “The decision-making process can’t be cookbook,” he says. “If you force patients into one treatment option, it may not be a good pathway for them.” MM
Scott Smith is a staff writer for Minnesota Medicine.