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Cleverly designed trial of surgery for lumbar herniation affirms a familiar theme: short-term benefits only

PainSci » bibliography » Gugliotta et al 2016
Tags: spine, back pain, intervertebral disc, pain problems

PainSci notes on Gugliotta 2016:

This trial of surgery had some interesting strengths and weaknesses: it was an observational study, with some clever compensations for the weaknesses of that design that made it more RCT-like, but while avoiding the usual gripes about RCTs (“lack of generalisability because patients who agree to be randomised in these trials may not be representative of those seen in clinical practice” — the full discussion will be of interest to research geeks).

And the result was indeed boringly and “remarkably similar to those reported in previous RCTs” — better results from surgery only at first, a familiar theme.

They “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.” And so, “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.”

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

OBJECTIVES: Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting.

METHODS: A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting.

RESULTS: 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.

CONCLUSIONS: 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.

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