One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study |
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| Authors: | Sohail K. Mirza Richard A. Deyo Patrick J. Heagerty Judith A. Turner Brook I. Martin Bryan A. Comstock |
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| Affiliation: | 1. Department of Orthopaedic Surgery and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA;2. Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098, USA;3. Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098, USA;4. Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098, USA;5. Center for Research in Occupational and Environmental Toxicology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098, USA;6. Department of Biostatistics, University of Washington, Box 357232, 1959 NE Pacific St, Seattle, WA 98195, USA;7. Department of Psychiatry and Behavioral Sciences, University of Washington, Box 356560, 1959 NE Pacific St, Seattle, WA 98195, USA;1. Institute Provvida Madre, Balerna, Switzerland;2. Researcher, Department of Business and Social Sciences, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland;3. Pediatrician, Mendrisio, Switzerland;4. Pediatric Orthopedic Department, University Children’s Hospital, Basel, Switzerland;5. Department of Pediatrics, Ospedale San Giovanni, Bellinzona, Switzerland;1. Departments of Child and Adolescent Psychiatry, Hacettepe University Children''s Hospital, Ankara, Turkey;2. Pediatric Neurology, Hacettepe University Children''s Hospital, Ankara, Turkey;3. Pediatric Gastroenterology, Hacettepe University Children''s Hospital, Ankara, Turkey;1. Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aoba-ku, Sendai 980-8574, Japan;2. Department of Orthopaedic Surgery, Sendai City Hospital, Japan;3. Department of Orthopaedic Surgery, Tohoku Kosai Hospital, Japan;4. Nakajo Orthopaedic Clinic, Japan;1. Department of Neurosurgery, Leiden University Medical Center, Postbus 9600, 2300 RC, Leiden, The Netherlands;2. Department of Radiology, Medical Center Haaglanden, Lijnbaan 32, 2512 VA, The Hague, The Netherlands;3. Department of Medical Decision Making, Leiden University Medical Center, Postbus 9600, 2300 RC, Leiden, The Netherlands;4. Department of General Practice, Erasmus Medical Center, University Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands;5. Department of Neurosurgery, Medical Center Haaglanden, Lijnbaan 32, 2512 VA, The Hague, The Netherlands |
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| Abstract: | Background contextThe clinical entity “discogenic back pain” remains controversial at fundamental levels, including its pathophysiology, diagnostic criteria, and optimal treatment. This is true despite availability of four randomized trials comparing the efficacy of surgical and nonsurgical treatments. One trial showed benefit for lumbar fusion compared with unstructured nonoperative care, and three others showed roughly similar results for lumbar surgery and structured rehabilitation.PurposeTo compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels.DesignProspective observational cohort study.Patient samplePatients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area.Outcome measuresRoland-Morris back disability score (primary outcome), current rating of overall pain severity on a numerical scale, back and leg pain bothersomeness measures, the physical function scale of the short-form 36 version 2 questionnaire, use of medications for pain, work status, emergency department visits, hospitalizations, and further surgery.MethodsPatients receiving spine surgery within 6 months of enrollment were designated as the “surgical treatment” group and the remainder as “nonsurgical treatment.” Outcomes were assessed at 3, 6, 9, and 12 months after enrollment.ResultsWe enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons. Eighty-six patients (17%) had surgery within 6 months of enrollment. Surgery consisted of instrumented fusion (79%), disc replacement (12%), laminectomy, or discectomy (9%). Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery. Adjusting for baseline differences among groups, surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified (23-point) Roland disability questionnaire (primary outcome) 1 year after enrollment. Using a composite definition of success incorporating 30% improvement in the Roland score, 30% improvement in pain, no opioid pain medication use, and working (if relevant), the 1-year success rate was 33% for surgery and 15% for nonsurgical treatment. The rate of reoperation was 11% in the surgical group; the rate of surgery after treatment designation in the nonsurgical group was 6% at 12 months after enrollment.ConclusionsThe surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines. |
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| Keywords: | Discogenic back pain Surgery Fusion Nonsurgical treatment Outcome |
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