Background/Purpose: Current evidence for outcomes of surgical versus conservative treatment of lumbar disc herniation with nerve root compression is ambiguous. To compare the effectiveness of surgical versus conservative treatment in patients with symptomatic lumbar disc herniation we followed cases prospectively in a quality control setting.

Methods: Validated instruments (North American Spine Society (NASS) questionnaire and SF-36) were used to measure patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were pain symptoms at 6 and 12 weeks after the end of the treatment. Conservative treatment encompassed ergonomic instruction, active physical therapy, education/counseling with instructions for home-based exercise, analgesia, physical therapy and periradicular infiltrations and/or radicular pulsed radiofrequency application. Surgical treatment consisted of standard open discectomy and the appropriate components of the conservative approach. Effectiveness was assessed at 6, 12, 52, and 104 weeks after the end of the treatment.

Only cases with non-missing primary outcome data were included in the analysis. Missing data was filled in with multiple imputations, and mixed-effects models were used to account for repeated measures within cases. Baseline group differences were adjusted for by inverse probability weighting.

Results: Three-hundred-and-seventy patients were consecutively sampled and assigned to surgical (n=297) or conservative (n=73) treatment. Patients receiving surgical treatment tended to have more severe neurogenic symptoms at baseline (P=0.098) and were more likely to be from a higher social class (P=0.065). There was no significant difference between groups for all variables at baseline after adjustment using inverse probability weighting (P≥0.72).

Patients receiving surgical treatment reported less back pain than those receiving conservative treatment at 6 week follow-up (-0.97; 95% confidence interval -1.89 to -0.09), had a higher proportion with ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% confidence interval 0.16 to 0.47), and less physical function disability at 1 year follow-up (-3.7; 95% confidence interval -7.4 to -0.1). For other assessments, between-group differences were minimal for all outcomes, with confidence intervals including the null effect.

Conclusion: Surgical treatment appears to provide faster relief for back pain symptoms than conservative treatment in the management of patients with lumbar disc herniation. However, surgical treatment did not show a clear benefit over conservative treatment in mid- and long-term follow-up.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/comparison-of-surgical-and-conservative-therapy-of-lumbar-disc-herniation-with-radicular-signs-and-symptoms-in-a-quality-management-program/