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Surgery, Nonoperative Care Relieve Herniated Disc Pain Equally, Study Says

November 21, 2006 at 6:35 PM EDT
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JIM LEHRER: Now, new word today on treating back pain, with or without surgery. Our health correspondent Susan Dentzer is here with the details.

A new study. What was its basic findings, Susan?

SUSAN DENTZER, NewsHour Health Correspondent: Jim, the basic finding pertained to surgery for a herniated disc. This is what happens when the little doughnut-shaped things in between your vertebrae actually rupture.

It’s kind of like a worn tire that develops a little bubble. You get this little bubble in the disc. A little jelly-like fluid leaks out. It impinges on the nerves and actually gets quite inflamed, and that’s what gives you these sensations of sciatica, these shooting pains down your back side or in your leg.

The question has been: Should you get surgery for that? Or could you treat it non-operatively, that is, with physical therapy, with injections of steroids, with medications like ibuprofen that you can get over the counter, et cetera? The studies published today said you can get both and you’ll have roughly equal outcomes with either surgery or with non-operative care.

JIM LEHRER: First of all, how common is this particular ailment?

SUSAN DENTZER: It’s very common. It tends to strike people in their thirties to fifties, in middle age. It’s due in part to genetics, probably also to some wear and tear. One out of four people actually…

JIM LEHRER: There’s no single cause of this, right?

SUSAN DENTZER: No, no single, but there’s obviously a genetic predisposition.

JIM LEHRER: Sure.

SUSAN DENTZER: And interestingly enough, about one in four middle-aged adults will actually have herniated discs…

JIM LEHRER: One of four?

SUSAN DENTZER: One out of four.

JIM LEHRER: Wow.

SUSAN DENTZER: Not anywhere near that are symptomatic. Basically, only one out of every 100, three out of every 300, roughly speaking, have these horrible, painful symptoms…

Surgery as a treatment

JIM LEHRER: That's the symptom? That's the symptom, is pain, right?

SUSAN DENTZER: That's the symptom, is pain.

JIM LEHRER: And that is the only symptom, right?

SUSAN DENTZER: Well, pain and a lot of misery that comes about from it, and lost work days, other things that flow from that.

JIM LEHRER: OK, now how prevalent was surgery or is surgery, as a treatment?

SUSAN DENTZER: Surgery is very prevalent. And even more interestingly enough, it's very disparate around the country. You can have -- a study was done a couple of years ago looking at the rate at which Medicare patients get this surgery for a herniated disc. And it showed that there are eightfold variation. In Mason City, Iowa, you were eight times as likely to get this surgery as you were in the Bronx or even in Honolulu. So there was no real scientific consensus whether this surgery helped or not.

JIM LEHRER: And that's kind of suspicious in and of itself, is it not?

SUSAN DENTZER: Very much so, which is why this study was devised, to try to test what the proper approach was.

The study and its findings

JIM LEHRER: Now, tell us the study, and how they went about it, and who did it.

SUSAN DENTZER: It was done by a number of academic medical centers around the country, a total of 13, 140 different doctors participating.

JIM LEHRER: These are medical schools, university medical schools?

SUSAN DENTZER: These are medical schools, Dartmouth-Hitchcock in New Hampshire being the lead, in effect. And, in effect, what happened was patients were divided into several groups. Some patients -- a total of about 500 -- were split into a randomized group. They were randomly assigned to either get surgery or to get the non-operative care.

JIM LEHRER: But were the same symptoms, same diagnosis?

SUSAN DENTZER: Roughly speaking, the same symptoms. Another group of patients were actually not randomly assigned. They were allowed to make up their own minds on the basis of their own informed judgment what they wanted to do. And about 700 of those went into the so-called observational arm of the study. And then everybody was followed for up to two years after they had whatever they had or didn't have, and then to see what happened.

JIM LEHRER: So is this a stunning revelation, I mean, a stunning result that you could treat it with exercise and that sort of thing, or you can treat it with surgery and the result is essentially the same?

SUSAN DENTZER: It's very surprising to many. There are, of course, many physicians in the country who believe that surgery is the right care. And, in fact, patients who suffer from this are routinely told that, if they don't have surgery, they may undergo paralysis later on. It turns out that that's not true, if you look at the...

JIM LEHRER: The study establishes that?

SUSAN DENTZER: Absolutely, because if you look at the patients who did not undergo surgery who made the decision to have post-operative care, their symptoms improved almost as much, and they didn't undergo paralysis.

People's reaction, possible fallout

JIM LEHRER: Now, what's been the reaction to this? This was published in the Journal of the American Medical Association.

SUSAN DENTZER: Yes, today.

JIM LEHRER: Today. What's been the reaction?

SUSAN DENTZER: Well, a lot of the beauty of this is in the eye of the beholder, like many things in medicine.

JIM LEHRER: Yes, OK.

SUSAN DENTZER: Many people who tend to be of the view that surgery is the preferred mode look at some signs, particularly in the observational end of this study, and say surgery probably is a little bit better.

Here's what happened. In the random part of the trial, a lot of patients who were assigned to get surgery didn't get it, decided not to get it. A lot of patients who were assigned not to get the surgery went on to get it. And so, if you look at all of that, it confounds the results a little bit.

So what people say is, let's look at the other study where people made up their own minds, and the people who decided to get surgery there reported that they felt better afterwards. So the people who like surgery look at that and say, "See? Surgery was a little bit better."

JIM LEHRER: So what's the likely fallout from this to be? What's going to happen because of this?

SUSAN DENTZER: The lead investigators hope that what comes out of this is an agreement that the best choice, the right rate of surgery or of non-operative care, is what informed patients decide to do once they're presented with all of the evidence.

JIM LEHRER: But isn't that a cop-out, Susan? I mean, how is an ordinary patient going to make that kind of decision?

SUSAN DENTZER: Well, if patients can be shown that they're, roughly speaking, equal outcomes if they have surgery or not, they can decide, "Boy, you know, I'd rather not run the risks," or, "I just would prefer a non-invasive procedure," or, "Maybe if I could just get a few steroid shots and feel just as well, maybe I'll do that."

And interestingly, next year we'll have the part of the analysis that shows what the cost impact of all of this is.

JIM LEHRER: What is it? Roughly now, what is it?

SUSAN DENTZER: Well, we don't really know...

JIM LEHRER: Why not?

SUSAN DENTZER: ... because, of course, if you don't have surgery, you're still going to the doctor. You're still seeing physical therapists, and you're still getting injections. So there is still cost attendant not having surgery.

But the betting is probably the surgery is going to end up costing a little bit more. We'll see when the analysis comes out, and then we'll really know, what's the most cost-effective way to approach this, in addition to just alleviating symptoms?

Complications and risks

JIM LEHRER: Did the study -- quickly, before we go -- did the study find any downside to surgery? Were there complications as a result of surgery that there wouldn't have been if they had left it alone?

SUSAN DENTZER: Very, very minimal. Very minimal. It's an easy procedure. It's quickly done in this day and age. It's very easy to discern that you have a herniated disc because of new imaging techniques, and it's easy to remove the disk or a part of it.

So the real issue is, just as the researchers say, this comes down to patient preference. They should look at the data, look at the evidence, know that either way they go they're probably going to improve and take it from there.

JIM LEHRER: Is it likely that the significance of this study will be greeted by doctors on both sides of this argument, as, say, "OK, let me re-examine my approaches?" Is it that significant?

SUSAN DENTZER: Probably so, and certainly this big variation that we get around the country that clearly makes no sense. I mean, there's no reason there should be eight times as much surgery; that will probably be reduced as really people take stock of what appropriate care really is.

JIM LEHRER: OK. Susan, thank you very much.

SUSAN DENTZER: Thanks, Jim.