The 8 year follow-up from the Spine Patient Outcomes Research Trial (SPORT) disk herniation study was published in the January 1 issue. The spine community has become familiar with this study over the years, and this latest installment provides important long-term outcome data that should provide patients and their providers with important information to help guide their treatment choices. Interestingly, there were almost no changes in outcomes from 4 to 8 years, with the surgery group maintaining their statistically and clinically significant advantage over those treated non-operatively on essentially all outcome measures. While both groups improved significantly compared to baseline, the surgery group improved about 10 points more on the SF-36 physical function and bodily pain scales as well as on the Oswestry Disability Index (ODI). Scrutiny of the data demonstrates that there were really no significant changes after 1 year. Similar to prior studies, the only outcome measure that was not improved with surgery was return to work. The 8 year re-operation rate was 15%, a relatively low rate compared to the 25% 10 year re-operation rate reported by the Maine Lumbar Spine Study (MLSS).1 Approximately 85% of the re-operations were for reherniation at the same level, which suggests the 8 year rate of reherniation leading to repeat surgery is about 9% (versus 6% at 4 years2). While the benefits of surgery are made clear by this paper, it is notable that 34% of enrolled patients never underwent surgery, and 75% of those who initially chose non-operative surgery also avoided surgery. Given that all patients met relatively stringent inclusion criteria that would be considered clear indications for surgery, it is notable that so many managed to avoid surgery if that was their treatment preference.
This study represents the most comprehensive long-term study of lumbar disk herniation and had similar outcomes to the other two long-term studies that have looked at this topic. The MLSS reported a significant treatment effect of surgery on most outcomes measures at 10 years, and Weber et al. reported better outcomes with surgery at 10 years compared to non-operative treatment, though the differences were no longer significant at that point (this early study was underpowered and long-term crossover limited power even further).1,3 While SPORT was challenged with substantial crossover and loss to follow-up (37% at 10 years), the advanced analytical techniques employed hopefully mitigated some of the potential confounders. No study is perfect, but the balance of the evidence now suggests that diskectomy leads to a faster and greater degree of recovery than non-operative treatment, and this benefit is maintained in the long-term. Conversely, many patients improve significantly with non-operative treatment and are satisfied with their results. This study provides patients with good long-term data indicating that both surgical and non-operative treatment are safe and effective and will hopefully help guide them through an informed, shared-decision making process.
Please read this article in the January 1 issue. Does it change the way you see long-term outcomes in lumbar disk herniation patients? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine 2005;30:927-35.
2. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine 2008;33:2789-800.
3. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine 1983;8:131-40.