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Medpundit has a pretty good explanation of the recent study about herniated disk surgery. Basically it works, but if you wait two years, then the results are about the same as non-surgical treatment—roughly 70% of people get better, and there doesn’t appear to be any long-term harm from delaying surgery. As I have someone very close to me with a current case of extreme back and leg pain from a herniated disk, I’m very interested in the study, and actually more inclined to suggest surgery (especially arthroscopic) sooner rather than later. But in this case the patient, doctor and other advisors are more in favor of waiting it out.

So on a global level it’s more cost-effective not to do the surgery. But on an individual level it probably lessens the pain—and the pain is close to unbearable, and if you have to put up with it for several months, then surgery is probably an option the patient will want.

Note that this is only the case for herniated disks and not lots of the other back issues for which surgery is probably ineffective–but still done at a very high rate.

The good news is that ten years after AHCPR (the forerunner to AHRQ) was decimated by daring to discuss back surgery, we’re getting studies out about this type of issue. Even, as Medpundit points out, it’s not a great study and it’s very, very hard to do studies about this type of intractable medical problem.

CODA: One slightly disquieting anecdote. I asked a local back specialist (non-surgeon) what the best way of doing surgery was (open or athroscopic). He said that the choice depended mostly on the training of the surgeon! Er…shouldn’t the surgeon be trained in the most advanced manner? (I expect those who know to chime in here)

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19 Responses for “QUALITY: The herniated disk story”

  1. pgbMD says:

    I have had multiple HNPs in my neck, thoracic and lumbar spine over the years. They mostly caused pain but the lumbar ones did cause some temporary mild foot drop. After reviewing the literature, I elected not to undergo surgery and just waited it out. I kept working out in the gym and for a while just concentrated on situps, etc. I also bought a hottub, inversion table and tempurpedic mattress (can writeoff cost on taxes if above 7.5% of AGI). They all got better on their own except for the residual chronic pain but you learn to live with it. Of course, if I had more significant motor deficits I probably would have elected for surgery. Additionally, there are the occassional horror stories of people undergoing surgery that end up with complications such as bowel or bladder incontinence. Bottom-line, approach surgery with caution!

  2. Eric Novack says:

    Matthew- 1. its endoscopic, not arthroscopic, surgery in the back.
    2. “most advanced” does not equal better necessarily.
    3. further proof of the difficulty identifying the ‘outcomes’ so many want judged.
    4. the data is far more interesting when viewed with the recent Dartmouth CECS report showing a 20-fold variation in spinal fusion rates depending upon where you live….
    bottom line — get data, ask questions, get multiple opinions and recognize that (as I tell my patients daily), if any one doctor had all the answers, he or she should get a white tent and travel the countryside.

  3. Matthew Holt says:

    Eric. When I rule the world, you will be given a white tent! Thanks for taking the hint!

  4. Matthew Holt says:

    BTW what’s the difference between endoscopic and arthroscopic. I thought arthroscopic was joints and endoscipic was holes

  5. Jojo says:

    I’ve had 3 back surgeries over the years for a number of different problems in my lower back including herniated disks and a bone spur impacting the sciatica nerve. Techniques have advanced a great deal over the years and for most surgeries, recovery is fairly quick. I last had a herniated disk taken care of and a bone spur surgically removed in December 2000. I went in on Thursday morning for the surgery, was walking around the hospital and up and down stairs on Friday and went home on Saturday. I was back working out in the gym in 5 weeks and playing tennis in the spring. I go on long hikes of 12 miles or so regularly now. Every now and then I still have an occasional stab of sciatica pain down my left leg, particularly after a couple sets of heavy tennis but this is manageable.
    No one should live in pain if they have a medical plan. If you have to take more than an occasional Ibuprofen or Celebrex, then you should consider getting surgery. I waited a long time for my first surgery (1987), went through Chiropractic (stay away from this BS!), acupuncture, heat treatments, ultrasound, etc. I couldn’t sit in a regular chair without sitting on telephone books, couldn’t sleep on my left side, was always in pain, etc., etc. But the doctors kept telling me to hold off on surgery, you don’t really need it, these exercises should help, yada, yada, yada. Finally I couldn’t take the pain anymore and demanded something had to be done! When they did an MRI and the spinal dye stuff, they immediately scheduled surgery for the next day. They said the disc was so herniated that it was a few scant mm from hitting the nerve that controlled my bladder function and cutting it off! Sheese.
    The thing I most remember upon waking up after the surgery was the complete absence of pain (and it wasn’t because of any drugs since I had asked for only a light, quick-acting general anesthetic)). It was wonderful to be without pain! Similarly after each of my other surgeries.
    Unfortunately, due to continuing deterioration in my lower back, I’ll eventually probably have to look into a fusion or artificial discs for at least 2 discs in my lower spine (4 & 5).
    Of course, it is critical to get the right doctor. My last 2 surgeries were in San Francisco and were done by Dr. Light out of St. Francis hospital. I would highly recommend him. Do a Google search on him.

  6. C. DuBois says:

    Matthew, as a recently trained spinal surgeon (finished my fellowship in 2004) hopefully I can help clarify things. Arthroscopic(within joints) and endoscopic procedures are both performed using a monitor instead of direct visualization (as in an open surgery). At this date, true endoscopic surgery for herniated discs (via a percutaneous approach) is not as commonly performed. The “open” procedure your friend is speaking about is likley a “mini-open” procedure done through a 2-3 inch incision. The less invasive option (and becoming more common as surgeons are trained in the technique), is a minimally invasive technique through a 18mm-22mm incision via a tubular retractor, under a microscope (in effect, direct visualization). Both techniques (mini-open and minimally invasive) share almost identical outcomes.
    The interesting thing about the study from last week, is that none of the information is anything we didn’t already know. There have been other papers in the literature that have demonstrated equal efficacy b/tw surgery and conservative care (in the long term). Most spine surgeons will also agree that unless the patient has an obvious neurologic deficit, it would be rare to have any permanent neurologic sequale (also well supported in previous studies).
    In my practice, I will always explain that, in all liklihood, things will improve regardless of the patient’s decision to operate. What surgery does do is speed the rate at which return to function occurs.
    The irony of all of this is that of all the spinal procedures with questionable benefit, the current discussion is about a procedure with sucess rates in the high 90s%.
    In response to pgbMD, complications such as permanent neurologic deficit or bowel or bladder incontinence are exceedingly rare after discectomy. The incidence of nerve root injury (permanent or temporary) has been reported as 0.2%, and infection at 0.5%-1.0%. This is a safe procedure (in the right hands) and in my practice is performed as an out-patient.

  7. pgbMD says:

    I agree that the incidence of such devastating injuries such as bowel and bladder incontinence after discectomy are exceedingly rare, but nevertheless they are still present. I also agree that the results are surgeon dependent.

  8. CB says:

    This thread is old, but I’m curious to know more about the efficacy of microdiscectomy and possible deleterious side-effects.
    I have Ehlers-Danlos syndrome and 2 extruded disks in my back. One extrusion is causing partial foot drop and the symptoms have been unchanged for a month.
    My doctor says that without intervention and without spontaneous improvement, the neurological impairment will become permanent, but I hesitate to operate, given the fact that my spine is already structurally unstable due to the EDS.
    How long can I go with the foot drop without it becoming permanent?
    Will this surgery cause instability in my spine and make future problems worse?
    What about stents? Is it possible to put a stent around the nerve to protect it from the extruded disk material? Will this help with stability?
    I appreciate any response. My email is cpondwork at yahoo.
    -CB

  9. CB says:

    Hey, I got a microdiscectomy if anyone reads this. It’s working well for me so far.
    -CB

  10. Joanna says:

    My Mom who is now 55 had a slipped disc operated on 11 years ago. Not long after her surgery she started to lose her balance. After MANY tests and a couple of years she was diagnosed with ataxia (sporadic). Her cerebellum has been shrinking every since and she has lost ALL coordination, speech, swallowing, and more! Today she lies in a hospice and is in her last days (55 years old). I am sure and always have been that the surgery she had for the slipped disc was the cause of all this. She was very active and healthy before all of this and we have no family history of anything like this. If anyone has an opinion on this I would love to hear it please (joannauga@comcast.net)

  11. For hernaited disc surgery it is important to consider the individual case. Where is the pain located, what is the level of function of the patient, are they improving with natural history or with conservative treatment. As with any surgery, there are always risks. The patient should ask the surgeon the benefits and the risks before deciding on an invasive option for herniated disc surgery.
    Sandra McFaul

  12. I agree with the post about judging on a case by case basis. Many will resolve with conservative care 70-90% depending on the source. However prior to surgery for disc herniation I have most of my patients evaluated for epidural steroid injection. This at times can be a less invasive way of getting pain and symptomatic relief.

  13. I am definitely not a doctor, but I HAVE thrown my back out a few times.
    I found out about the following exercises, which have really helped me out quite a bit (do a youtube search for more thorough descriptions):
    1. MacKenzie Pressups – 10 reps
    2. Hip extensions – 8 reps x 5 sec hold
    3. Birddog – 4 reps x 10 sec hold
    4. Side bridges – 5 reps x 10 sec hold on each side
    See if these work for you.
    -Ian

  14. lumbar pain says:

    The body has a powerful ability to heal itself.

    The body’s structure (mainly the spine) and its function are closely related, and this relationship affects health.

    Chiropractic therapy is given with the goal of normalizing the relationship between structure and function and helping the body as it heals.

  15. Dr. Mroski says:

    I have been treating patients with disc problems for the last 18 years and have had a lot of success in helping most of them resolve their problems non-surgically. Of course, there is a small percentage that fail conservative care and end up going through with surgery. Interestingly, I have treated a large number of patients who failed microdiscectomy within 6 months of the procedure who had fantastic results with spinal decompression and chiropractic care.

  16. Joe says:

    “Chiropractic therapy” is voodoo cult nonsense.

  17. An inversion table would probably help with back pain – at least it has helped for me!

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