title: Lumbar disc herniation in the Spine Patient Outcomes Research Trial: does educational attainment impact outcome?
abstract: METHODS
  Randomized trial with concurrent observational cohort. A total of 1171 patients were divided into subgroups by educational attainment: high school or less, some college, and college degree or above.
  
  
  OBJECTIVE
  To assess the influence of education level on outcomes for treatment of lumbar disc herniation.
  
  
  BACKGROUND
  Educational attainment has been demonstrated to have an inverse relationship with pain perception, comorbidities, and mortality.
  
  
  METHODS
  The Spine Patient Outcomes Research Trial enrolled surgical candidates (imaging-confirmed disc herniation with at least 6 weeks of persistent signs and symptoms of radiculopathy) from 13 multidisciplinary spine clinics in 11 US states. Treatments were standard open discectomy versus nonoperative treatment. Outcomes were changes from baseline for 36-Item Short Form Health Survey (SF-36), bodily pain (BP), and physical function (PF) scales and the modified Oswestry Disability Index (ODI) at 6 weeks, 3 months, 6 months, and yearly through 4 years.
  
  
  RESULTS
  Substantial improvement was seen in all patient cohorts. Surgical outcomes did not differ by level of education. For nonoperative outcomes, however, higher levels of education were associated with significantly greater overall improvement over 4 years in BP (P = 0.007), PF (P = 0.001), and ODI (P = 0.003). At 4 years a "dose-response" type relationship was shown for BP (high school or less = 25.5, some college = 31, and college graduate or above = 36.3, P = 0.004) and results were similar for PF and ODI. The success of nonoperative treatment in the more educated cohort resulted in an attenuation of the relative benefit of surgery.
  
  
  CONCLUSIONS
  Patients with higher educational attainment demonstrated significantly greater improvement with nonoperative treatment while educational attainment was not associated with surgical outcomes.
authors.affiliation: Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
authors.forename: Patrick R
authors.initials: PR
authors.lastname: Olson
authors.forename: Jon D
authors.initials: JD
authors.lastname: Lurie
authors.forename: John
authors.initials: J
authors.lastname: Frymoyer
authors.forename: Thomas
authors.initials: T
authors.lastname: Walsh
authors.forename: Wenyan
authors.initials: W
authors.lastname: Zhao
authors.forename: Tamara S
authors.initials: TS
authors.lastname: Morgan
authors.forename: William A
authors.initials: WA
authors.lastname: Abdu
authors.forename: James N
authors.initials: JN
authors.lastname: Weinstein
mesh_terms: D000328:Adult; D015331:Cohort Studies; D004185:Disability Evaluation; D004522:Educational Status; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007403:Intervertebral Disc / Q000473:pathology* / Q000503:physiopathology; D007405:Intervertebral Disc Displacement / Q000601:surgery* / Q000628:therapy*; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D010147:Pain Measurement / Q000379:methods / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013997:Time Factors