DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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Herniated disc disease – conservative therapy works

How often do we hear this story? We have a commonly accepted treatment which under rigorous scrutiny does not make a long term difference.

One of my very well known national colleagues had a herniated disc several years ago. He read all the literature and decided to take a conservative approach. Over time he improved and was able to return to his previous activity level (he is a runner).

I was surprised that he did not elect surgery, but given today’s JAMA articles I see his wisdom.

For Herniated Lumbar Disk, Medical Therapy Matches Surgery

For patients with a herniated lumbar disk, surgery and usual care appeared equally effective in reducing pain and disability over two years, according to two studies.

It was essentially a draw in the first randomized trial of lumbar diskectomy or to nonoperative individualized treatment for patients with lumbar disk intervertebral herniation, said investigators here.

Irrespective of the therapy, patients improved substantially and for the most part equally, James Weinstein, D.O., of Dartmouth Medical School here, and colleagues reported in the Nov. 22/29 issue of the Journal of the American Medical Association.

In a companion observational study of patients who declined to be randomized in the first trial but chose their own treatment, the results were similar, giving a slight edge to surgery, found a second report in the same issue of JAMA.

However, according to the researchers, a similar group in both studies, and two editorial writers, both studies had unavoidable methodological flaws, making it difficult to reach firm conclusions.

Many patients randomized to surgery declined to have surgery, and a significant number of medically treated patients eventually chose surgery. As in all such studies, comparing these groups does have significant challenges.

If I had a herniated disc and sciatica, I would try conservative therapy first, and only resort to surgery if the pain and my quality of life worsened significantly. If I had a neurologic deficit (such as foot drop) I would immediately choose surgery.

While there are flaws in this study (which we cannot blame on the investigators, but rather the nature of the symptoms), the study does encourage us to more aggressively try conservative therapy in patients who would rather avoid surgery.

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