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CONTROVERSIES IN SPINE SURGERY

Should Initial Management for Lumbar Herniated Nucleus Pulposus Resulting in a Dense Nerve Palsy Be Surgical

Shenoy, Kartik MD; Goz, Vadim MD; Levine, Marc J. MD; Kaye, I. David MD

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doi: 10.1097/BSD.0000000000000922
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NO

Lumbar disk herniations are among the most common causes of lumbar radiculopathy but there is still debate over an optimal treatment algorithm. Several high-quality studies have examined operative and nonoperative treatments for this condition.1–6 Although the largest, the SPORT trial and Main Lumbar Spine Study,1,3 have concluded that surgery is better than nonoperative management over the long term, ideal timing remains controversial. Given the natural history of the disease, and the risks and benefits of nonoperative versus operative management, we propose that even in the setting of motor weakness, at 3 weeks, initial management for a lumbar herniated disk is nonoperative.

Data from the SPORT trial documents a clear benefit to surgery over nonoperative treatment.1,7,8 The as-treated analysis favors surgery in all primary and secondary outcomes investigated including Short Form-36, Oswestry Disability Index, Sciatica bothersomeness index, self-rated improvement and satisfaction with symptoms. Although patients on average did better with surgery, it is important to note that a significant proportion of patients in the SPORT trial were satisfied with the outcomes of nonoperative treatment. Overall, 75% of patients that initially chose nonoperative treatment were successful in avoiding surgery through the 8-year follow-up. In addition, the risks of surgery are not negligible.

In a study of 34,639 lumbar disk surgeries for herniated nucleus pulposus, Fjeld et al9 report a 2.7% surgical complication rate, 2.1% rate of repeat surgery within 90 days, and additional 2.4% rate of nonsurgical readmissions. An additional risk is the prospect of reoperation beyond 90 days, frequently due to reherniation, which occurred at a rate of 15% over 8 years in the SPORT trial data.1 The reviewed literature suggests that while on average operative treatment outperforms nonoperative treatment, it comes with the risk of perioperative complications, while a significant portion of patients treated nonoperatively are satisfied with the results and avoid surgery.

Given the potential success of nonoperative treatment and the low likelihood but present risks of operative intervention, the pivotal question becomes “What is the downside of initial nonoperative management and the delay of potential operative intervention?” The highest quality data once again comes from the SPORT trial. Rihn et al10 investigated the impact of symptom duration on the outcomes of both operative and nonoperative treatment utilizing the as-treated analysis of the SPORT trial cohort. The authors found that patients that have had symptoms for over 6 months duration do worse than patients that have had symptoms for <6 months. This is true for both the nonoperative and operative treatments. Interestingly, the operative cohort demonstrated a treatment benefit over nonoperative treatment in both the <6-month group and >6-month group, and the difference in treatment effects is not statistically significantly different between <6- and >6-month groups. In other words, the benefit of surgery over nonoperative treatment is not diminished if the patient has symptoms for over 6 months compared with <6 months.

These findings are in concert with a number of other studies. Nygaard et al11 investigated 132 consecutive patients undergoing microdiscectomy and found that patients that had leg pain for >8 months had worse self-reported outcomes after microdiscectomy compared with those with <8 months of symptoms, but there was no difference in less than or greater than 4 months. Ng and Sell12 investigated 113 consecutive patients that underwent lumbar discectomy and found that the mean change in the Oswestry Disability Index was similar in patients that had symptom duration of up to 1 year, but worse after 1 year of symptoms. Peul and colleagues conducted a randomized controlled trial of 283 patients with lumbar disk herniation and radicular symptoms for 6–12 weeks before presenting comparing surgery within 2 weeks versus nonoperative treatment for 6 months followed by surgery if needed. Although there was an early benefit to surgery, the authors found no difference in outcomes at the 1- and 2-year follow-up.13 Overall, 56% of patients randomized to the conservative treatment cohort avoided surgery at 2 years.

In summary, a significant proportion of patients with radiculopathy secondary to herniated nucleus pulposis can effectively be treated with nonoperative treatment and avoid the costs and risks of surgery. The cohort of patients that do end up undergoing surgery have better outcomes if the presence of symptoms has been <6–8 months depending on the specific study. The highest quality evidence suggests that there is no change in the treatment effect of surgery with the initial attempt of nonoperative treatment of up to 6 months. Giving patients adequate information to make informed decisions with the physician is fundamental for the timing of surgery.

YES

First described by Mixter and Barr14 in 1934, lumbar discectomy is performed to decompress the irritated nerve root by removal of pathologic disk material within the spinal canal and/or neuroforamen. Since then, multiple studies, most notably the Maine Lumbar Spine Study and the Spine Patient Outcomes Research Trial, have demonstrated the superiority of surgical intervention for lumbar herniated nucleus pulposis (LHNP).1,15 Although these and other studies support surgical intervention, the natural history of LHNP is typically of symptom resolution with time and therefore nonoperative management is often the first step. However, in the case of neurological deterioration or dense deficit, expectant management may not provide adequate resolution and surgical intervention may be more strongly warranted.

Furthermore, expectant management can decrease the quality of life and can be an economic burden on the patient and their workplace.

While more recent high-quality studies have demonstrated superiority for operative versus nonoperative management for LHNP, a landmark paper by Weber16 in 1983 reported equivalent results. Although surgical patients performed better initially, by 4 years, the improvement was no longer statistically significant.16 Although this paper is commonly cited in support of initial nonoperative treatment, the cohort of patients with clear indications for surgery consisted of 67 patients with severe and immobile scoliosis, intolerable pain, suddenly occurring and/or progressing muscle weakness, and/or bladder/rectal paresis. This group was not further stratified and therefore the number of patients purely with a dense nerve palsy is unknown. More recently, studies have attempted to specifically examine outcomes of surgical patients with nerve palsies secondary to LHNPs and have found superior outcomes from early surgical intervention. Given more recent promising data, surgical treatment should be the initial management for a dense nerve palsy due to an LHNP with 3 weeks of symptoms.

Many studies have sought to determine whether the duration of preoperative symptoms is related to recovery. Schoenfeld and Bono17 tried to answer this question in a systematic review of 11 studies with regards to LHNPs. They found that longer duration of symptoms led to worse outcomes after lumbar discectomy. Ng and Sell12 showed that a longer duration of leg pain was associated with a smaller improvement in Oswestry Disability Index after surgical intervention. One limitation of these studies is that the stratification of early versus late surgery is on the order of months. Schoenfeld and Bono found a difference at >6 months and Ng and Sell found a difference after 1 year. Quon et al18 attempted to look at the effects of delayed surgery but with an earlier time cutoff for delayed treatment and found that waiting >12 weeks increased the likelihood of experiencing worse pain at 6 months postoperatively. This study suggests that there may be cellular changes to the nerves occurring earlier which may be the cause of poor results postoperatively.

With respect to neurological deficits, most studies support early operative intervention. Two retrospective studies by Aono and colleagues19,20 in 2007 and 2014 found that the duration of nerve palsy had the greatest influence on recovery suggesting that earlier intervention led to a better functional recovery and surgical outcome. However, in both studies, although they compare 2 durations of symptoms, they do not define what is considered early versus late. Postacchini et al,21 in a cohort of 116 patients, reported that those with severe deficits who had surgery within 1 month of symptom onset had a complete recovery. This suggests that surgical intervention at our 3-week cutoff would lead to a better recovery. A more recent study by Overdevest et al22 found that early surgical intervention led to faster recovery of motor deficit initially, however at 1 year, there was no significant difference when compared with prolonged conservative treatment. Although at 1 year there was no difference, earlier recovery can expedite return to function and return to work helping to lessen associated costs of LHNPs.

The economic burden associated with back pain, let alone radiculopathy and neurological deficit is significant. van Tulder et al23 conducted a study in the Netherlands to estimate the costs of back pain to society and found that in general musculoskeletal disease is the most expensive with regards to absenteeism and disability and that back pain accounts for one third of musculoskeletal disease. Similarly, Peul et al24 found that lumbar spine disorders rank fifth with regard to hospital costs and result in even higher costs from absenteeism and disability. It is clear that that back pain creates a significant economic burden and LHNPs are definitely a portion of this problem. To mitigate this cost, one could argue that when a surgical indication such as a neurological deficit is present, the cost of operating would offset the potential cost of absenteeism and disability associated with expectant management. Furthermore, not only is waiting costly, but Nygaard et al11 found that patients who delayed surgery by taking sick leave preoperatively were at a higher risk of not returning to work. Consequently, surgical care can actually be cost-saving when considering lost productivity and disability.25 In addition, when directly comparing the direct costs of surgical versus nonsurgical care, despite surgical care being more costly, it has been shown to be more cost-effective with regards to the quality of life, work loss, and health outcomes.25

In conclusion, for a lumbar disk herniation resulting in a dense neurological deficit, there are many downsides to delaying operative care. Not only is there the potential for a worse outcome with respect to disability and pain but there is also the economic cost of lost work time and potentially permanent absenteeism due to disability. Expediting care and returning patients to a functional state will minimize the economic burden while maximizing the likelihood of a better outcome. Therefore, for a patient with a dense neurological deficit due to lumbar disk herniation with 3 weeks of symptoms, we would recommend surgical intervention over expectant management.

REFERENCES

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