Slipped Disc: Surgery Best for Pain?

With time -- and medical help -- slipped disc pain gets better. But disc surgery is faster and works better for bad pain, a large U.S. study finds.

The study shows that patients with a "slipped" or "ruptured" disc -- what doctors call a herniated disc --won't get worse or become paralyzed if they don't have surgery. Instead, they can expect to get better over time.

But when patients don't want to wait, surgery can mean a quick end to excruciating pain, says study researcher William A. Abdu, MD, medical director of the spine center at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H.

"Patients with disc herniation can get better without an operation," Abdu tells WebMD. "But those who have severe leg pain -- and can't function well -- clearly will have improved outcomes if they have the operation."

Slipped Disc = Herniated Disc = Pain

Rubber-like discs pad the bones of the spine. When one of these discs bulges out into the spinal canal, it tends to push against the root of a nerve.

This causes intense back pain. Depending on which nerve is affected, pain or tingling may run down into the buttocks, hip, and leg.

With a combination of pain treatment, proper exercise, and rest, the pain often goes away or becomes only a minor nuisance.

Doctors usually consider surgery to remove the offending disc -- a discectomy -- if the pain continues for six weeks.

But some patients who've had the surgery say it wasn't worth it. And sometimes the pain of a herniated disc later gets better without surgery.

So is surgery really the best option?

That's a controversial question. There have been clinical trials in the past, but various flaws have made them difficult to interpret.

So Abdu and colleagues took a new look at the issue. Their study focused on problems with the lower back.
Waiting Works, Surgery Works Better

Dartmouth researcher James N. Weinstein, DO; Abdu; and their colleagues compared disc surgery to treatment with education and counseling, non-steroidal pain drugs, narcotic pain drugs, physical therapy, and/or steroid injections.

They gave 1,244 patients with herniated discs in the lower back a choice. The patients could let a computer assign them to either surgery or nonsurgical treatment for two years. Or they could pick one of the two options themselves.

Some 500 patients said they'd let the computer decide, although many of them soon reneged and chose the treatment not picked by computer.

The result: After two years, nearly all the patients were doing better.

However, those who got surgery reported slightly better results than those who got nonoperative care.

Another 743 patients said from the start that they'd make their own choice between surgery and nonoperative care.

After two years, all of those patients were doing a lot better.

But those who chose surgery reported the best quality of life and the least pain.

What all this means to Abdu is that patients have to decide. For some, the right decision is surgery. For others, the right decision is avoiding surgery.

"Our study would suggest that, regardless of how you are treated for a herniated disc, you will likely get better over time," he says.

But, "If your pain is intolerable, you will be much better after the operation," he says. "You may still have a little pain or numbness -- but the chances of this are much less with than without the operation."

The study appears in the Nov. 22/29 issue of The Journal of the American Medical Association.
A Surgeon's Opinion

What do surgeons say about the study findings?

WebMD asked Andrew M. Casden, MD, associate director of the Spine Institute at Beth Israel Medical Center, and assistant professor at Albert Einstein College of Medicine.

Casden says the Dartmouth study isn't going to change things very much. He notes that candidates for disc surgery have already wated six to eight weeks for their pain to subside.

"The question: How long is someone willing to live with pain?" Casden tells WebMD. "A lot of these people are in terrible pain. They have to get back to work, back to taking care of their families.

"Even if, after two years, the results are similar for surgery and for nonsurgery -- well, most people don't have the luxury of waiting around that long," says Casden.

In an editorial accompanying the Dartmouth study, Stanford University researcher Eugene Carragee, MD, strikes much the same note as Casden. He calls the study a "colossal" effort that provides fascinating insight into modern patient preferences.

Like Casden, Carragee says the bottom line is the amount of pain a patient is willing to put up with.

"If the main benefit from surgery is that patients perceive a more rapid resolution of disabling pain, the question for patients may be how bad they feel and how urgently they wish to achieve relief in the next two to four months," Carragee says.

SOURCES: Weinstein, J.N The Journal of the American Medical Association, Nov. 22/29, 2006; vol 296: pp 2441-2450 and 2451-2459. Carragee, E. The Journal of the American Medical Association, Nov. 22/29, 2006; vol 296: pp 2485-2487. William A. Abdu, MD, associate professor of orthopedic surgery, Dartmouth University; medical director of spine center, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Andrew M. Casden, MD, associate director, Spine Institute, Beth Israel Medical Center; assistant professor, Albert Einstein College of Medicine.