EVIDENCE-BASED ANSWER
YES, in the short term. Patients with an acute episode of low back pain, radicular symptoms, and evidence of a herniated disc on imaging may experience short-term pain relief from discectomy if their symptoms haven’t improved after initial conservative therapy (strength of recommendation [SOR]: A, multiple randomized, controlled trials [RCTs]).
Although surgery may enhance pain relief initially, no evidence supports a long-term benefit for surgery over conservative management (SOR: A, multiple RCTs).
Evidence summary
Disc herniation is defined as any protrusion of the disc nucleus, cartilage, or other associated tissues from the normal disc space. Lumbar disc herniations (LDHs) are most likely to occur in the L4 to L5 and L5 to S1 levels, causing low back pain and sciatica. Many LDHs occur without symptoms, however, so it’s important to correlate level and side of herniation before assuming causality. Expert opinion recommends early surgical intervention for patients with cauda equina syndrome or progressive neurologic deficits.1
Surgery provides short-term gains
A search identified 4 RCTs that compared surgical intervention with conservative management. The first, published in 1983, evaluated 126 patients with radicular pain and confirmed LDH who did not improve after 2 weeks of conservative therapy. The study assigned patients to either open discectomy or back school.2 Patients rated their results as good, fair, poor, or bad; a good or fair rating was considered a positive outcome.
At 1 year, significantly more patients in the surgery group reported positive results (P<.001), based on working capacity, neurological deficits, pain, and lumbar spine mobility. At 4 years, no significant difference was found between the groups.
The study showed significant crossover, with 26% of conservatively managed patients receiving surgery within the first year. Evaluators weren’t blinded, and outcome measurements weren’t based on standardized evaluation tools.
Crossover complicates comparison of relative treatment effects
The Spine Patient Outcomes Research Trial (SPORT), published in 2006, compared 501 patients with confirmed LDH and persistent symptoms after 6 weeks.3 Patients were randomized to open discectomy or nonoperative “usual care.” Both groups showed improvement in pain scores and no significant differences in standardized pain scales at 3 months, 1 year, or 2 years.
Crossover for the study was high: 40% of the surgical group didn’t have surgery, and 45% of the nonoperative group underwent surgery. Although the pattern of care in the SPORT study resembles common clinical situations,4 the high degree of crossover makes it difficult to draw inferences about relative treatment effects.5
Greater patient satisfaction with surgery
Another RCT followed 56 patients with confirmed LDH and symptoms for 6 to 12 weeks.6 Patients were randomized to receive microdiscectomy within 2 weeks of randomization or nonoperative care. Outcomes were based on standardized pain scales for leg and back pain. The surgical group had significantly better leg pain relief (P<.01) at the 6-week evaluation. At 12 weeks, neither back pain nor leg pain differed between the groups.
Although pain didn’t differ significantly, patients in the surgical group were more satisfied with their care, and physicians were more likely to believe that surgery would improve outcomes. Crossover from the nonoperative group was high, with 39% of that group undergoing surgery.