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Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial

Lurie, Jon D., MD, MS*; Tosteson, Tor D., ScD*; Tosteson, Anna N. A., ScD*; Zhao, Wenyan, PhD*; Morgan, Tamara S., MA*; Abdu, William A., MD, MS*; Herkowitz, Harry, MD; Weinstein, James N., DO, MS*

doi: 10.1097/BRS.0000000000000088
Randomized Trial

Study Design. Concurrent prospective randomized and observational cohort studies.

Objective. To assess the 8-year outcomes of surgery versus nonoperative care.

Summary of Background Data. Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical with nonoperative treatment remain controversial.

Methods. Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting Spine Patient Outcomes Research Trial eligibility criteria enrolled into prospective randomized (501 participants) and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual nonoperative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain and Physical Function scales and the modified Oswestry Disability Index-AAOS/Modems version assessed at 6 weeks, 3 months, and 6 months, and annually thereafter.

Results. Advantages were seen for surgery in intent-to-treat analyses for the randomized cohort for all primary and secondary outcomes other than work status; however, with extensive nonadherence to treatment assignment (49% patients assigned to nonoperative therapy receiving surgery versus 60% of patients assigned to surgery) these observed effects were relatively small and not statistically significant for primary outcomes (bodily pain, physical function, Oswestry Disability Index). Importantly, the overall comparison of secondary outcomes was significantly greater with surgery in the intent-to-treat analysis (sciatica bothersomeness [P > 0.005], satisfaction with symptoms [P > 0.013], and self-rated improvement [P > 0.013]) in long-term follow-up. An as-treated analysis showed significant surgical treatment effects for primary outcome measures (mean change, surgery vs. nonoperative care; treatment effect; 95% confidence interval): bodily pain (45.3 vs. 34.4; 10.9; 7.7 to 14); PF (42.2 vs. 31.5; 10.6; 7.7 to 13.5); and Oswestry Disability Index (−36.2 vs. −24.8; −11.3; −13.6 to −9.1).

Conclusion. Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients; there was little to no degradation of outcomes in either group (operative and nonoperative) from 4 to 8 years.

Level of Evidence: 2

Eight-year results of the Spine Patient Outcomes Research Trial (SPORT) are detailed, including discussion of crossover and comparisons to similar trials. At 8 years, patients who had surgery for intervertebral disc herniation maintained greater improvement than those who remained nonoperative.

*Geisel School of Medicine at Dartmouth, Hanover, NH, and Dartmouth-Hitchcock Medical Center, Lebanon, NH; and

William Beaumont Hospital, Royal Oak, MI.

Address correspondence and reprint requests to Jon D. Lurie, MD, MS, Associate Professor, Department of Medicine, of Orthopaedics, and of the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock, One Medical Center Dr., Lebanon, NH 03756; E-mail:

Acknowledgment date: September 4, 2013. Revision date: October 14, 2013. Acceptance date: October 15, 2013.

†Died June 7, 2013.

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

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01-AR45444; P60-AR062799) and the Office of Research on Women's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention grant funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants, stocks.

© 2014 by Lippincott Williams & Wilkins