Surgical vs Nonoperative Treatment for Lumbar Disk Herniation

Weinstein, James Neil; Lurie, Jon D.; Tosteson, Tor D.; Skinner, Jonathan; Hanscom, Brett; Tosteson, Anna N.A.; Herkowitz, Harry N.; Fischgrund, Jeffrey S.; Cammisa, Frank P.; Albert, Todd J.; Deyo, Richard A.

doi:10.1001/jama.296.20.2451

Cited by 643 publications

(202 citation statements)

References 22 publications

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“…There is conflicting evidence on the benefits of surgery for degenerative spine disease, and interpretation of our disparity findings is further complicated by the extensive regional and physician variation in rates of spine surgery. 81–84 It is impossible to say if either of the rates of surgery experienced by HIV infected or uninfected patients were appropriate.…”

Section: Discussionmentioning

confidence: 99%

Disparities in Rates of Spine Surgery for Degenerative Spine Disease Between HIV-Infected and Uninfected Veterans

King

Gordon²,

Perkal³

et al. 2012

Spine

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Study Design Retrospective analysis of nationwide Veterans Health Administration (VA) clinical and administrative data. Objective Examine the association between HIV infection and the rate of spine surgery for degenerative spine disease. Summary of Background Data Combination anti-retroviral therapy (cART) has prolonged survival in patients with HIV/AIDS, increasing the prevalence of chronic conditions such as degenerative spine disease that may require spine surgery. Methods We studied all HIV infected patients under care in the VA from 1996–2008 (n=40,038) and uninfected comparator patients (n=79,039) matched on age, gender, race, year, and geographic region. The primary outcome was spine surgery for degenerative spine disease defined by ICD-9 procedure and diagnosis codes. We used a multivariate Poisson regression to model spine surgery rates by HIV infection status, adjusting for factors that might affect suitability for surgery (demographics, year, comorbidities, body mass index, cART, and laboratory values). Results Two-hundred twenty eight HIV infected and 784 uninfected patients underwent spine surgery for degenerative spine disease during 700,731 patient-years of follow-up (1.44 surgeries per 1,000 patient-years). The most common procedures were spinal decompression (50%), and decompression and fusion (33%); the most common surgical sites were the lumbosacral (50%), and cervical (40%) spine. Adjusted rates of surgery were lower for HIV infected patients (0.86 per 1,000 patient-years of follow-up) than for uninfected patients (1.41 per 1,000 patient-years; IRR 0.61, 95% CI: 0.51, 0.74, P<0.001). Among HIV infected patients, there was a trend towards lower rates of spine surgery in patients with detectable viral loads levels (IRR 0.76, 95% CI: 0.55, 1.05, P=0.099). Conclusion In the VA, HIV infected patients experience significantly reduced rates of surgery for degenerative spine disease. Possible explanations include disease prevalence, emphasis on treatment of non-spine HIV-related symptoms, surgical referral patterns, impact of HIV on surgery risk-benefit ratio, patient preferences, and surgeon bias.

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Section: Discussionmentioning

confidence: 99%

Disparities in Rates of Spine Surgery for Degenerative Spine Disease Between HIV-Infected and Uninfected Veterans

King

Gordon²,

Perkal³

et al. 2012

Spine

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“…These spines underwent MR imaging to determine degeneration grade and T 2 relaxation times (Kerttula et al, 2001; Marinelli et al, 2010; Pfirrmann et al, 2001). The L5-S1 disc was selected for testing because herniations and discectomies are most common at this level (Weinstein et al, 2006). Samples had degeneration grades ranging from 1 to 5 and T 2 relaxation times ranging from 66 to 204, with higher relaxation times indicating healthier discs.…”

Section: Methodsmentioning

confidence: 99%

Nucleotomy reduces the effects of cyclic compressive loading with unloaded recovery on human intervertebral discs

Showalter

Malhotra

Vresilovic

et al. 2014

Journal of Biomechanics

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The first objective of this study was to determine the effects of physiological cyclic loading followed by unloaded recovery on the mechanical response of human intervertebral discs. The second objective was to examine how nucleotomy alters the disc’s mechanical response to cyclic loading. To complete these objectives, 15 human L5-S1 discs were tested while intact and subsequent to nucleotomy. The testing consisted of 10,000 cycles of physiological compressive loads followed by unloaded hydrated recovery. Cyclic loading increased compression modulus (3%) and strain (33%), decreased neutral zone modulus (52%), and increased neutral zone strain (31%). Degeneration was not correlated with the effect of cyclic loading in intact discs, but was correlated with cyclic loading effects after nucleotomy, with more degenerate samples experiencing greater increases in both compressive and neutral zone strain following cyclic loading. Partial removal of the nucleus pulposus decreased the compression and neutral zone modulus while increasing strain. These changes correspond to hypermobility, which will alter overall spinal mechanics and may impact low back pain via altered motion throughout the spinal column. Nucleotomy also reduced the effects of cyclic loading on mechanical properties, likely due to altered fluid flow, which may impact cellular mechanotransduction and transport of disc nutrients and waste. Degeneration was not correlated with the acute changes of nucleotomy. Results of this study provide an ideal protocol and control data for evaluating the effectiveness of a mechanically-based disc degeneration treatment, such as a nucleus replacement.

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“…16 Somewhat less definitive conclusions were reported in the Spine Patient Outcome Research Trial, which examined patients who had surgery versus nonoperative treatment for lumbar disc herniation. 17 In this study, it was shown that after 3 months the operated group had greater improvement in terms of bodily pain, physical function, and Oswestry Disability Index. However, these improvements were narrowed after 2 years of follow-up.…”

Section: Discussionmentioning

confidence: 57%

Nucleoplasty is Effective in Reducing Both Mechanical and Radicular Low Back Pain

Shabat¹,

David²,

Folman³

2012

Journal of Spinal Disorders & Techniques

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Surgical vs Nonoperative Treatment for Lumbar Disk Herniation

Abstract: clinicaltrials.gov Identifier: NCT00000410.

Cited by 643 publications

References 22 publications

Disparities in Rates of Spine Surgery for Degenerative Spine Disease Between HIV-Infected and Uninfected Veterans

Disparities in Rates of Spine Surgery for Degenerative Spine Disease Between HIV-Infected and Uninfected Veterans

Nucleotomy reduces the effects of cyclic compressive loading with unloaded recovery on human intervertebral discs

Nucleoplasty is Effective in Reducing Both Mechanical and Radicular Low Back Pain

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