People who opt for surgery to treat chronic back and leg pain from a herniated disc may do slightly better when compared with non-surgical treatments, but the difference is not significant, U.S. researchers say.
In a herniated disc, the doughnut-shaped soft tissue cushioning the vertebra in the back protrudes, putting pressure on the spinal nerves, a conditionthat can be painful. A herniated disc is most common in the lower back.
It is themost common surgical procedure performed in the U.S. for back and leg pain.
Herniated discs can improve with time and with exercise, and differences in surgery rates across the U.S. and internationally led researchers to question whether the operation is appropriate and useful.
James Weinstein of Dartmouth Medical School inHanover, N.H., and his colleagues compared surgical and non-operative treatment for herniated discs in 1,200 people over four years. Some participants were randomly assigned to a treatment while others chose for themselves.
"Patients in both the surgery and non-operative treatment groups improved substantially over the first two years," the researchers report Wednesday in the Journal of the American Medical Association.
After two years, patients tended to say surgery provides more relief than physical therapy, especially at first, for sciatica and other pain.
In the randomized trial, people who did not get the surgery were offered physical therapy, education and counselling on how to do exercises at home, and non-steroidal anti-inflammatory drugs.
A second observational study of patients with persistent sciatica who had the surgery or usual care found those who chose surgery said they experienced greater improvement.
But people who ask for surgery may have more severe disease and expect that the operation willhelp, making them different from non-surgical patients, Dr. David Flum, of the University of Washington in Seattle, cautioned in an accompanying editorial.
"Given the large number of patients potentially exposed to the risks of these strategies, a sham surgical trial may be the only effective and ethical next step" to compare the risks and benefits of the surgery, Flum concluded.
Concerns of worsening back problems, neurological breakdown, numbness and paralysis in the legs, buttocks or genitals from leaving a herniated disc untreated were unfounded, said Eugene Carragee of Stanford University Medical Center in a secondeditorial.
"The fear of many patients and surgeons that not removing a large disc herniation will likely have catastrophic neurological consequences is simply not borne out," Carragee wrote.
Decide treatment based on pain perception
Once those complications are ruled out, patientsshould make a treatment decision based on how much pain they can live with, said Dr. Michael Goyten,an orthopedic surgeon and head of the spine program at Winnipeg's Health Sciences Centre.
"Although the outcomes might be the same at two years, well, two years is a lot of time â¦to take off in terms of inability to work, or if you're caring for children at home or maintaining a household."
There are no unnecessary surgeries done in Canada, because long wait times and limited resources mean patients and doctors try to find alternatives, Goyten added.
Some chiropractors saidthey feel vindicated by the study, which confirms what they've been saying for decades.
"Surgery is always an option, but possibly not the first option," said chiropractor Zsolt Egey-Samu of Winnipeg. "Let's see what their bodies can do. If they don't need the surgery then it frees up time for other people that really do."