To Cut Or Not To Cut

About 300,000 Americans have surgery each year for herniated disks. With total hospital, anesthesia and surgery costs running around $10,000 to $15,000 per operation, that works out to up to $4.5 billion worth of surgery annually. Is it worth it? Maybe. And maybe not. A report in this week's issue of the Journal of the American Medical Association (JAMA) found that herniated disk patients who did not opt for surgery did nearly as well as those who went under the knife after a two-year period. And the researchers said the differences in outcome between the two approaches were "small and not statistically significant."

The multi-center Spine Patient Outcomes Research Trial (SPORT) enrolled 501 surgical candidates with severe leg pain and operated on half of them. The randomized clinical trial found that patients who had surgery and patients who did not both “improved substantially over a two-year period.” However, a second, observational trial (also in JAMA this week), in which patients chose which treatment they wanted, showed a different result. The 528 patients who had surgery reported greater improvements than the 191 patients who did not have an operation. In general, researchers put less stock in observational studies than in randomized ones, in part because of the possibility of a placebo effect.

So where does that leave all those folks with aching backs who are trying decide whether to get surgery for a herniated disk? "It's clearly a patient’s choice,” says the lead author of both studies, Dr. James Weinstein of Dartmouth Medical School. With either approach, “patients got remarkably better,” says Dr. David Flum, director of the Surgical Outcomes Research Center at the University of Washington and author of one of the editorials accompanying the studies. “Both approaches are reasonable.”

Surgery to remove an errant piece of disk is straightforward. Surgeons make a three-quarter-inch incision and pluck out the offending piece of disk with forceps. They do not insert plates and screws or remove much, if any, bone. “All they’re doing is removing a part of the disk and not doing much else,” says Dr. Rick Deyo, professor of medicine and health services at the University of Washington and a co-author of the two studies. “You’re just taking out a bad part of the disk.” Surgery generally takes 45 minutes to an hour. Patients go under general anesthesia, but often go home the day of the operation.

So, who should get surgery, and who should just say no? “It’s got to be a very individualized decision that involves a patient’s own priorities,” says Deyo. “Are you risk averse and prefer to avoid surgery? If so, you’ll probably get better. Are you a risk taker and prefer surgery. If so, you’ll probably get better faster, and it’ll cost a little bit more.” Doctors generally advise patients to wait six weeks from the time they develop the pain to see how much they improve on their own.

If the pain is bearable, patients may want to forgo the operation. “Patients often don’t realize that they’re very likely to get better, even without surgery. It’s just likely to be slower,” says Deyo. “Time is on their side.” If he had a herniated disk, Deyo would make his decision based on how much it “interfered” with his life. He might “ride it out” if he had some tingling in his leg that didn’t interfere too much, he says. “They really are individual decisions.” Even without surgery, there can be complications. People who skip surgery may continue to visit the doctor for treatments, including epidural steroids and anti-inflammatory drugs. In some cases, their spouses need to take off from work to care for them.