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Lumbar Disc Herniation in the Spine Patient Outcomes Research Trial: Does Educational Attainment Impact Outcome?

Olson, Patrick R., MD, MS, MPH*; Lurie, Jon D., MD, MS†,‡,¶; Frymoyer, John, MD§; Walsh, Thomas, MS, MSPT; Zhao, Wenyan, MS*,‡; Morgan, Tamara S., MA*,‡; Abdu, William A., MD, MS*,¶,‖; Weinstein, James N., DO, MS*,‡,¶

doi: 10.1097/BRS.0b013e31820bfb9a
Health Services Research

Study Design. Randomized trial with concurrent observational cohort. A total of 1171 patients were divided into subgroups by educational attainment: high school or less, some college, and college degree or above.

Objective. To assess the influence of education level on outcomes for treatment of lumbar disc herniation.

Summary of Background Data. Educational attainment has been demonstrated to have an inverse relationship with pain perception, comorbidities, and mortality.

Methods. The Spine Patient Outcomes Research Trial enrolled surgical candidates (imaging-confirmed disc herniation with at least 6 weeks of persistent signs and symptoms of radiculopathy) from 13 multidisciplinary spine clinics in 11 US states. Treatments were standard open discectomy versus nonoperative treatment. Outcomes were changes from baseline for 36-Item Short Form Health Survey (SF-36), bodily pain (BP), and physical function (PF) scales and the modified Oswestry Disability Index (ODI) at 6 weeks, 3 months, 6 months, and yearly through 4 years.

Results. Substantial improvement was seen in all patient cohorts. Surgical outcomes did not differ by level of education. For nonoperative outcomes, however, higher levels of education were associated with significantly greater overall improvement over 4 years in BP (P = 0.007), PF (P = 0.001), and ODI (P = 0.003). At 4 years a “dose-response” type relationship was shown for BP (high school or less = 25.5, some college = 31, and college graduate or above = 36.3, P = 0.004) and results were similar for PF and ODI. The success of nonoperative treatment in the more educated cohort resulted in an attenuation of the relative benefit of surgery.

Conclusion. Patients with higher educational attainment demonstrated significantly greater improvement with nonoperative treatment while educational attainment was not associated with surgical outcomes.

A subanalysis of the Spine Patient Outcomes Research Trial (SPORT) lumbar disc herniation cohorts found higher levels of education associated with significantly greater overall improvement for nonoperative outcomes. No differences between levels of education were found for operative outcomes. This resulted in a statistically significant decrease in the relative treatment effect of surgery across strata of educational attainment with the most highly educated groups experiencing the smallest relative advantage from surgery.

*Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH;

Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH;

The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH;

§College of Medicine, University of Vermont, Burlington, VT;

Dartmouth Medical School, Hanover, NH; and;

Spine Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Address correspondence and reprint requests to Tamara S. Morgan, MA, Research Manager, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756; E-mail:

Acknowledgment date: June 12, 2009. First revision date: August 10, 2010. Second revision date: November 24, 2010. Accepted date: December 13, 2010.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal funds were received in support of this work. One or more of the author(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript: e.g., honoraria, gifts, consultancies, royalties, stocks, stock options, decision making position.

Trial Registration: Identifier: NCT00000410

© 2011 Lippincott Williams & Wilkins, Inc.