title: Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial.
abstract: METHODS
  Concurrent prospective randomized and observational cohort studies.
  
  
  OBJECTIVE
  To assess the 8-year outcomes of surgery versus nonoperative care.
  
  
  BACKGROUND
  Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical with nonoperative treatment remain controversial.
  
  
  METHODS
  Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting Spine Patient Outcomes Research Trial eligibility criteria enrolled into prospective randomized (501 participants) and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual nonoperative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain and Physical Function scales and the modified Oswestry Disability Index-AAOS/Modems version assessed at 6 weeks, 3 months, and 6 months, and annually thereafter.
  
  
  RESULTS
  Advantages were seen for surgery in intent-to-treat analyses for the randomized cohort for all primary and secondary outcomes other than work status; however, with extensive nonadherence to treatment assignment (49% patients assigned to nonoperative therapy receiving surgery versus 60% of patients assigned to surgery) these observed effects were relatively small and not statistically significant for primary outcomes (bodily pain, physical function, Oswestry Disability Index). Importantly, the overall comparison of secondary outcomes was significantly greater with surgery in the intent-to-treat analysis (sciatica bothersomeness [P > 0.005], satisfaction with symptoms [P > 0.013], and self-rated improvement [P > 0.013]) in long-term follow-up. An as-treated analysis showed significant surgical treatment effects for primary outcome measures (mean change, surgery vs. nonoperative care; treatment effect; 95% confidence interval): bodily pain (45.3 vs. 34.4; 10.9; 7.7 to 14); PF (42.2 vs. 31.5; 10.6; 7.7 to 13.5); and Oswestry Disability Index (-36.2 vs. -24.8; -11.3; -13.6 to -9.1).
  
  
  CONCLUSIONS
  Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients; there was little to no degradation of outcomes in either group (operative and nonoperative) from 4 to 8 years.
  
  
  METHODS
  2.
authors.affiliation: *Geisel School of Medicine at Dartmouth, Hanover, NH, and Dartmouth-Hitchcock Medical Center, Lebanon, NH; and †William Beaumont Hospital, Royal Oak, MI.
authors.forename: Jon D
authors.initials: JD
authors.lastname: Lurie
authors.forename: Tor D
authors.initials: TD
authors.lastname: Tosteson
authors.forename: Anna N A
authors.initials: AN
authors.lastname: Tosteson
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: Harry
authors.initials: H
authors.lastname: Herkowitz
authors.forename: James N
authors.initials: JN
authors.lastname: Weinstein
mesh_terms: D000328:Adult; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000601:surgery / Q000628:therapy*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome