PT Classroom - Functional Outcomes of Lumbar Discectomy vs. Lumbar Fusion - a Literature Review ׀ by Kathryn Greaves, MPT

 

Kathryn Greaves graduated from UW- Madison with her Master of Physical Therapy degree. Her training in physical therapy includes orthopedics, sports medicine, vestibular and women’s health. While attending Madison, Kathryn was also a member of the UW- Madison Women’s hockey team.



The words “low back pain” are all too familiar to between 70-80% of Americans1. Often times this pain comes on without warning when getting out of bed, turning the wrong way or incorrectly lifting a heavy weight. However, there are still many cases when an individual cannot recall involvement in any activity which could have resulted in injury. Nevertheless, a MRI taken of the spine of this individual will display what is known as a herniated disc. Of these people, 2-10% will require surgery, most receiving discectomies2. However, when >200,000 Americans are receiving discectomies, we must consider the personal and economical costs that will follow.

There are many advantages to the advances in medical technology in which the U.S has to offer, but are we over utilizing and over spending because of it? In this literature review we will explore the pros and cons of surgical vs. non-surgical treatment of low back pain (LBP) of various origins.

Low back pain can be due to a herniated disc, osteoarthritis (joint degeneration), spondylolysis (vertebrae defect), spinal stenosis (narrowing of the spinal canal), as well as many other diagnoses. But what are the costs? Consideration must not only be given to the costs of the operation, but the cost spent for the patient to take off work, attend physical therapy before and after surgery and the possibility of having a re-operation should the surgery fail. Currently, the re-operation rate for a discectomy is 17-20%2.

 

Fusion is another surgical approach that doesn’t prove to have any more success with an average success rate of 68%2, yet this varies from study to study from 16-95%2. The bottom line with cost is that LBP has shown to be the most expensive benign condition in the U.S1. Therefore, patients need to analyze all the benefits and risks associated with different surgical options:
Discectomy14 - removal of herniated disc material that presses on a nerve root or the spinal cord.
– also used for bulging discs or ruptured discs.
– most effective type of surgery if failed nonsurgical treatment or have severe, disabling pain.
Laminotomy and laminectomy14 - relieves pressure on the spinal cord and/or spinal nerve roots caused by age-related changes in the spine.
– Laminotomy removes a portion of and
– Laminectomy removes all of the lamina on selected vertebrae and also may remove thickened tissue that is narrowing the spinal canal.
Percutaneous discectomy14
– A special tool is inserted through a small incision in the back
– Disc material is removed or destroyed to reduce pressure on the nerve root.
– Percutaneous discectomy is considered less effective than open discectomy3.
Instrumented Posterior Lumbar Fusion14
– a posterior approach to stabilize the vertebrae
– metal screws and rods (hardware) hold the vertebrae
– in place intended to stop movement from occurring between the vertebrae, give more stability to the fusion site and allow the patient to be out of bed much sooner


Newer Method:
Microendoscopic Discectomy(MED)
– METRx (Medtronic Sofamor Danek, Inc.) allows surgeons to address contained and sequestered fragments and lateral recess stenosis, with a minimally invasive approach (1/4 inch incision, using a camera to see the disc, surgeon performs it by watching the TVscreen)

On average, nearly 50% of patients with LBP from herniated discs will recover within 1 month, most will recover in 6 months5, yet 10% with significant pain remaining after 6 weeks will consider one of the above surgical options6. So, what does research tell us about these surgeries vs. traditional/non-surgical rehab?

In 1999, Donceel et al10. published their research on Return to work after surgery for lumbar disc herniation and found, of 710 patients randomly selected for either surgical of non-surgical treatment for a herniated lumbar disc, at 52 weeks only 10.1% of surgical patients had not returned to work vs. 18.1% of non surgical patients.

Four years later, Ivar et al.13 brought us a study on lumbar fusion vs. physical therapy for treatment of chronic LBP and disc degeneration. Sixty-four patients aged 25-60yo were recruited from Norway between 1997-2000, with LBP >1 year and evidence of L4/L5 and L5/S1 disc degeneration, were randomized to fusion and post-op physiotherapy (37 patients), or cognitive intervention (lecture about safety and use of back) and exercise (3 daily exercise sessions for 3 weeks). Results at 1 year indicated that pain and disability was significantly reduced after fusion compared to the control group, however, RTW, use of analgesics, emotional distress and life satisfaction were not different.

In 2005, Filiz et al1. presented his findings on The effectiveness of exercise programmes after lumbar disc surgery: a randomized controlled study where they compared intensive, classical and control group exercise programs and return to work (RTW) or daily activities (if not employed). The intensive group was educated and supervised in progressional dynamic stabilization exercises, the classical group performed McKenzie and Williams exercises, and the control group was told to be “as active as possible” in their daily activities. Results indicated that RTW or daily activities were significantly shorter (56 days) in the intensive group compared to all the others, and the classical (75 days) was significantly shorter than the control (86 days).

That same year, Atlas et al11 reported outcomes from a 1990-‘92 study of 507 patients comparing functional outcome measures 10yrs after patients received either a lumbar discectomy or non-surgical treatment for LBP. Results indicated that patients’ predominant symptom (low back or leg pain) was either “much better” or “completely gone” in 56% of surgical patients vs. 40% of non-surgical. Satisfaction rate was also greater in the surgical group, 70.5% vs. 55.5%. Yet disability and work status were similar across groups, and as time passed (up to 10 years) non surgical patients were functioning better than surgical patients with the opposite seen early post-op, as indicated above.

Research on the Microendoscopic Discectomy (MED) was presented by Wu et al.12 in 2006. It was determined that this approach was most appropriate for single level radiculopathy, secondary to lumbar disc herniation. There were 873 patients diagnosed with a lumbar disc herniation recruited from 2000-2003, with an average age of 41.5 yrs. These patients had experienced 6 weeks of unsuccessful rehab and were randomly allocated to either the experimental group receiving MED or the control group receiving an open posterior lumbar discectomy (flavectomy, laminotomy, nerve root retraction and discectomy). Results indicated that RTW/normal activities took 15 days for the MED group and was significantly fewer days than the control group at 21 days. At 28 months, the MED group had 79% relief of sciatica and 76% had no LBP. At 31 months, the control group had 72% relief of sciatica and 69% reported no LBP. Pain relief was statistically lower from pre-op to post-op in both groups. However, the surgeries performed later in the study had fewer complications leading the authors to conclude that the surgeon should have adequate knowledge and experience with the newer approach.

Other advanced surgical options in place of fusions are being used today including: Dynesys (1994): pedicle-screw system for mobile stabilization; Graf Ligamentoplasty: treats flexion instability (degenerative lumbar disorder, minimal disc space narrowing and facet arthrosis, but cannot correct vertebral slippage or deformity; X-Stop: rigid interspinous process distraction device designed to distract posterior elements of the stenotic lumbar segment and place it in flexion to treat neurogenic claudication by keeping canal open and limiting extension; and the 2004 FDA approved DePuy Spine’s CHARIT…™ Artificial Disc. However, long term studies clinical research studies have not been conducted.

So what does this tell us? First, if there are no significant neurological findings than the patient should attempt conservative treatment for 4 wks to 3 months after onset of discogenic LBP before considering surgery. Second, it is of economic importance to research and choose the surgery that has evidence based research to support its outcomes since every day earlier a patient returns to work there is a $200 savings3. Lastly, remember that surgery cannot fix muscle structure or function, successful rehabilitation is the key to a holistic recovery.

 

Last revised: April 10, 2008
by Kathryn Greaves, MPT

 

References

1. Filiz M, Cakmak A, and Ozcan E. The effectiveness of exercise programmes after lumbar disc surgery: a randomized controlled study. Clinical Rehab 2005;19: 4-11.
2. Mayer T, McMahon M, Gatchel R, Sparks B, Wright A and Pegues P. Socioeconomic outcomes of combined spine surgery and functional restoration in workers’ compensation spinal disorders with matched controls. Spine 1998: 23 (5): 598-605.
3. Scheer S, Radack K, and O’Brien D. Randomized controlled trials in industrial low back pain relating to return to work. Pat 1. Acute interventions. Arch Phys Med Rehabil 1995; 76: 966-73.
4. Sheer S, Radack K, and O’Brien D. Randomized controlled trials in industrial low back pain relating to return to work. Part 2. Discogenic low back pain. Arch Phys Med Rehabil 1996; 77: 1189-97.
5. Hu SS, et al. (2003). Lumbar disc herniation section of Disorders, diseases, and injuries
of the spine. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 3rd
ed., pp. 231-239. New York: McGraw-Hill
6. Jarvik JG, Deyo RA (2002). Diagnostic evaluation of low back pain with emphasis on imaging. Annals of Internal Medicine, 137: 586–597
7. North American Spine Society Task Force on Clinical Guidelines (2000). Herniated disc. North American Spine Society Phase III Clinical Guidelines for Multidisciplinary Spine Care Specialists. La Grange, IL: North American Spine Society
8. Atlas S, Keller R, Wu Y, Deyo R, Singer D. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine lumbar spine study. Spine 2005; 30(8): 936-943.
9.Molinari R. Dynamic stabilization of the lumbar spine. Curr Opin Orthop 2007; 18: 215-220.
10. Donceel P, Du Bois M, Lahaye D. Return to work after surgery for lumbar disc herniation. Spine 1999; 24 (9): 872-876.
11. Atlas S, Keller R, Wu Y, Deyo R, Singer D. Long-term outcomes of surgical and nonsurgical management of lumbar disc herniation: 10 year results from the Maine lumbar spine study. Spine 2005; 30(8): 927-35.
12. Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar disc herniation. Spine 2006; 31 (23): 2689-2694.
13. Ivar Brox J, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrighgtsen T, Eriksen H, Holm I, Koller A, Riise R, Reikeras O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercise in patients with chronic low back pain and disc degeneration (randomized trial). Lippincott Williams & Wilkins, Inc. 2003; 28 (17): 1913-1921.
14. www.southeasternspinecenter.com/svcs-gic an S.B., Wilk K. (2003). Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby.

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