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Acute Pain | Chronic Pain | General

Results after lumber discectomy for back/leg pain

 

Clinical bottom line

After lumbar discectomy for leg and back pain, 1 in 8 patients will have recurrent pain up to two years, and between 1 in 8 and 1 in 4 recurrent pain beyond two years. One patient in 20 will have recurrent disc herniation, which could involve greater complications beyond two years.


Reference

MJ McGirt et al. Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal. Neurosurgery 2009 64: 338-345.

Background

Lumbar discectomy is a common procedure for patients with persistent back and leg pain, particularly if it is unresponsive to non-invasive conventional therapies. Surgery tends to be of two types, a more aggressive approach involving removal of herniated disc fragments and curettage of the remaining disc, and a less invasive technique involving removal of fragments alone with little invasion of the disc space.

Issues with surgery involve shorter and longer term pain persisting, and injury to the disc and endplate of the vertebrae, with accelerated degenerative changes, disc space collapse, and potentially more or worse back and leg pain.

Study

This was a systematic review of case series reporting outcomes after limited and aggressive discectomy for primary lumbar disc herniation, with trials sought between 1980 and 2007, to reflect modern techniques. Only studies that reported, or had data allowing calculation of incidence of persistent pain in the shorter (6 months to two years) and longer term (more than two years), or recurrent disc herniation, were used.

The main results are shown in Table 1 and Figure 1. Persistent pain affected 14% of patients (1 in 7) between six months and two years. In the longer term, over two years, the incidence of persistent pain was much lower with limited discectomy (12%; 1 in 8) than after aggressive discectomy (28%; 1 in 4). The incidence of recurrent disc herniation was much lower with both techniques, at 7% after limited discectomy and 3.5% after aggressive discectomy, averaging 1 patient in 20.

Table 1: Main results for limited and aggressive discectomy

Outcome
Number of patients
Range
(%)
Overall incidence
(%)
Limited discectomy
Persistent pain (6 months to 2 years)
1434
7-26
15
Persistent pain (more than 2 years)
3263
7-16
12
Recurrent disc herniation
5832
2-18
7
Agressive discectomy
Persistent pain (6 months to 2 years)
4242
6-43
14
Persistent pain (more than 2 years)
1571
19-36
28
Recurrent disc herniation
6114
0-10
3.5

 

Figure 1: Longer term outcomes for limited and aggressive discectomy - persistent pain and recurrent disc herniation

Results

In 54 included studies involved 6,135 patients having limited discectomy and 7,224 having aggressive discectomy.

Comment

Perhaps the most useful result from this review is that it provides evidence of the success and failure rate with lumbar discectomy for leg or back pain. Most people, it would appear, have pain reduced to a point of not being clinically relevant, which is good. Some (between 1 in 8 and 1 in 4) will have persistent pain despite the surgery, and 1 in 20 will have recurrent herniation, potentially very bad news because it could lead to further problems.

It is possibly not entirely fair to make too many decisions about the type of surgery that is best, because as always with case series there is a host of reasons why results may be different, typically because of differences in case mix and initial pathology and severity.

What we do have is some numbers to put to patients considering surgery so that they can make an informed decision. The numbers we have put considerable weight on trying non invasive, or less invasive, interventions before resorting to surgery, though.