When should conservative treatment for lumbar disc herniation be ceased and surgery considered?

Abstract

Different authors recommend different time spans for conservative treatment before considering surgery in patients suffering from lumbar disc herniation. We analyzed the time of onset of symptoms such as pain, sensory deficit, and motor deficit in a surgically treated group in comparison to outcome after surgery in order to define a time threshold when surgical results deteriorate and operation should therefore be considered. General data, symptoms, signs, and neurological findings of 219 patients were preoperatively recorded. The outcome was evaluated according to the Prolo scale after a mean of 9.9 months. In the statistical workup, we calculated the duration of symptoms, sensory deficits, and motor deficit as continuous variables. Additionally, the population was divided into three groups of duration of symptoms, sensory deficit, or motor deficit for < or = 30 days, 30-60 days, and >60 days. Statistically significant predictors for unfavourable outcome were, for example, a longer duration of preoperative pain and motor and sensory deficit. Patients suffering for more than 60 days from disc herniation were found to have statistically worse outcome than patients suffering for 60 days or less. Findings were similar for the different time groups concerning the duration of sensory deficit but not for duration of motor deficit. The overall outcome seems to be better when patients are operated on for lumbar disc herniations within 2 months after onset of symptoms and sensory deficits. Due to these findings, we recommend conservative treatment up to 2 months and, if conservative management does not succeed, consideration of surgery.

Predictors of multidimensional outcome after spinal surgery

“…Whilst these variables have been identified as significant predictors of outcome in some retrospective studies (in which a limited number of ''readily available'' risk factors are typically examined), the majority of high quality prospective studies do not support a predictive role for them [15]. One of the risk factors commonly identified in previous studies, the duration of symptoms [11,19,21,24,29,32,33], was not shown to be a significant predictor in the present study. This may have been due to the paucity of acute patients in the study sample that would otherwise have provided a wider spectrum of values for this independent variable; a very high proportion of the whole sample (94%) were already ''chronic'' pain sufferers, according to the standard definition of >3 months pain.…”

The outcome of decompression surgery for lumbar herniated disc is influenced by the level of concomitant preoperative low back pain

“…The typical presentation is a patient with predominant radicular leg pain on one side, with or without additional neurological disturbances; the amount of concomitant low back pain can vary greatly. The treatment is initially conservative [23], but if this fails, then decompression surgery of the affected nerve root is usually performed, and is associated with a generally favourable outcome [1,12,27].…”

A decade’s experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000–2009

“…A practical screening tool to identify patients at risk of long-term sick leave may further enhance cost-effectiveness [35]. In case of severe relapsing low back pain despite conservative treatment and when surgery is perceived as an invaluable option, intervention needs to be performed without undue delay [36][37][38].…”