Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery: A prospective cohort study

BACKGROUND CONTEXT: Lumbar disc herniation (LDH) is associated with great morbidity and significant socioeconomic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients in whom pain and disability are unacceptable, surgical intervention provides effective clinical relief. Currently there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome.

PURPOSE: The aim of this study is to evaluate if prolonged symptom duration is correlated with less favorable outcome following surgery for LDH.

STUDY DESIGN/SETTING: Consecutive series of patients from a single-center, multi-surgeon, tertiary spine practice.

PATIENT SAMPLE: Consecutive series of patients who underwent surgery for lumbar disc herniation.

OUTCOME MEASURES: Oswestry Disability Index (ODI), EuroQol-5D (EQ-5D) and Visual Analog Scale (VAS) for back and leg pain (0 to 100).

METHODS: Patients with a first episode LDH were included. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their preoperative self-reported duration of leg pain: <3-months, 3-12 months and >12-months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. Statistical significance level was set at p-value <0.01.

RESULTS: There were 2,144 patients included in the study, with complete one-year follow-up on 1,694 patients (79%) and a reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain, however, this did not reach statistical significance (p=0.039). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) one year after surgery (p=0.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=0.008) of increasing incidence of reoperation was found with increasing length of symptom duration.

CONCLUSIONS: Delayed surgical intervention results in inferior outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved significantly better outcome one year after surgery when compared to the other groups.