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Public release date: 30 December 2007
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Surgery or Watchful Waiting for Lumbar Disk Herniation?
Long-term results are comparable, so patient choice plays a big role.
The best approach to a patient with acute lumbar disk herniation is unclear, to some extent because strictly
randomized trials in this area are difficult to conduct. Three studies suggest that patient choice might be
the most important factor.
In one study, 472 U.S. patients with acute lumbar radicular pain and corresponding positive imaging results
were randomized to diskectomy or conservative care. Crossover to the alternate intervention was relatively
common (40%–45%). Both groups improved substantially after 2 years of follow-up, with no difference noted by
an intent-to-treat analysis. In an accompanying observational study of 743 patients who declined randomization,
528 chose surgery and improved somewhat more in pain and physical function than did those who chose conservative
therapy. Surgery recipients tended to be younger and to have more severe symptoms at baseline than did those
who chose conservative management (Journal Watch Nov 28 2006).
In another study, 283 Dutch patients, similar to those described above, were randomized to surgery or
conservative treatment. Crossover rates were lower (11%–39%) than in the previous study. Surgical patients
improved more initially than conservatively managed patients, but the groups were similar by 1 year (Journal
Watch May 30 2007).
Patient preference is a huge factor in our approach to acute disk herniation, both in initial clinical
decision making and in subsequent decisions to try other therapies, as in these quasi-controlled trials.
Based on these studies, we reasonably can tell patients that most of them are likely to get better by 1 year,
whether or not they undergo surgery. For those who are impatient with the conservative approach, who have
minimal medical comorbidity, and who are at low risk for surgical complications, or for those whose pain
is unbearable, early surgery is reasonable. For those who would like to try conservative management (or
eventually opt for surgery, depending on their degree of pain resolution), outcomes are comparable to those
of early surgery. An editorialist notes that the uncertainty here will be resolved only with a trial that
includes a sham-surgery control, which he believes would be justified ethically; however, recruitment for
such a trial likely would be very difficult (Journal Watch Nov 28 2006).
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine December 28, 2007
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