Married patients benefit from herniated spinal disc surgery

Some patient subgroups see greater improvement after surgery for herniated spinal discs relative to nonoperative outcomes—notably including married patients whose symptoms are getting worse, reports a study in the January 15, 2012, issue of Spine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Although essentially all subgroups do better with surgery compared to nonoperative treatment, the new results may provide a better idea of the relative benefits of surgical versus nonsurgical treatment for herniated discs in individual patients. The lead author was Dr Adam Pearson of Dartmouth Medical School, Lebanon, N.H.

Overall Results Are Better with Surgery for Herniated Discs…
The researchers analyzed data from the Spine Outcomes Research Trial (SPORT)—one of the largest clinical trials of surgery for spinal disorders. In SPORT, patients meeting strict criteria for intervertebral disc herniation (or other common causes of back pain) were randomly assigned to surgery or nonsurgical treatment.

Over four years, the study showed a "clear benefit" of surgery for herniated discs. However, the findings at the group level didn't account for the wide range of factors—including demographic, radiographic (x-ray), clinical, and psychological characteristics—that can affect individual responses to treatment.

Toward determining which patients benefited most from surgery, the researchers compared outcomes for subgroups of patients defined by 37 different variables. The focus was on the "treatment effect" of surgery—that is, how much patients improved with surgery, above and beyond the improvement with nonsurgical treatment.

…But Some Subgroups Benefit More Than Others
"All analyzed subgroups improved more with surgery than with nonoperative treatment," Dr. Pearson and colleagues write. However, several different characteristics—such as marital status, education, duration of symptoms, and having a workers' compensation claim—seemed to influence the extent of improvement with surgery.

On analysis adjusting for all of the different variables, three factors were independently related to a greater treatment effect. The treatment effect of disc surgery was greater for married people, for patients who did not have problems with other joints (hip, knee, etc), and for patients whose back pain symptoms were getting worse at the time of treatment.

Overall, surgery produced the greatest improvement for married patients with worsening symptoms. In this subgroup, the treatment effect of surgery was about 18 points on a 100-point disability rating scale: a 38-point improvement with surgery versus a 20-point improvement with nonsurgical treatment). By comparison, the treatment effect for single patients with stable symptoms was about 8 points: 35 points with surgery versus 27 points without surgery.

It's unclear why marital status would affect the response to surgery, although studies have shown better outcomes for married patients with a wide range of health problems. The effect of worsening symptoms isn't surprising, as these patients were already getting worse without surgery. The absence of other joint problems may be an indicator of better general health.

Dr. Pearson and coauthors believe their results may help doctors and patients to predict the benefits of surgery for a herniated disc in individual patients. They emphasize that all patients should undergo "a thorough shared decision making process educating them about the risks, benefits and likely outcomes of surgical and nonoperative treatment." In the future, "real time computer models" may be developed to compare the likely outcomes of surgical versus nonsurgical treatment, based on patient characteristics.

Source: Spine