Q: How Long Can You Wait Before Getting Help for That Lumbar Disc

A: Many people with lumbar disc herniations opt for a wait-and-see approach to treatment. And that approach is usually recommended by most surgeons. But can you wait too long? Does the duration of symptoms have an unfavorable effect on final outcomes? This is the focus of a study conducted as part of the Spine Patient Outcomes Research Trial (SPORT).

The SPORT database provides information and data from 13 multidisciplinary spine practices across the United States. By combining patient information, studies like this make it possible to get more statistically accurate analysis of risk factors and variables (like duration of symptoms) that might affect treatment results.

In fact, it's studies like SPORT that have made it possible to see that surgery for lumbar disc herniation yields better results than conservative (nonoperative) care. But the question of when it's best to have that surgery remains unknown.

Patients in this study were divided into two groups: those who had symptoms for six months or less and those who had symptoms for more than six months. The researchers compared these two groups within two larger groups: those who had surgery and those who didn't. And in case you are wondering, surgery consisted of a traditional open incision discectomy (removal of the disc). Conservative care included physiotherapy, antiinflammatory drugs, education, and/or counseling.

Results were based on change in pain, other symptoms (e.g., leg pain, numbness, weakness), and physical function. Comparisons were made from baseline to follow-up four years later. They found worse results in patients who waited more than six months to get treatment. This was true for both groups (operative versus nonoperative). But the duration of symptoms did not seem to be a factor or reason why patients responded better to surgery.

The natural next-step in a study like this is to look at the two groups of patients (symptoms less than six months, symptoms more than six months) and see if there's more to it than just a number of pretreatment months. In this study, there were 927 patients in the six months or less group and 265 in the more than six months group.

The differences observed between the two groups were listed as more depression and a sense that the symptoms were getting worse in the six months or more group. Patients who had surgery sooner had more severe symptoms early on.

The patients who had surgery were also more likely to show more than just a protruding disc on MRIs -- the discs were often more out of the disc space than in. There were also a higher number of patients with severe symptoms less than six months' duration with sequestered types of herniation. Sequestered means a portion of the disc has been pinched off and separated from the rest of the disk. The free-floating fragment can create serious problems if it presses against the spinal cord or spinal nerve roots.

The authors concluded that symptom duration is a factor that should be paid close attention to. Whether treatment is conservative or with surgery, patients who had intervention of some kind within the first six months had better results.

It is still recommended that patients try conservative care first for symptomatic lumbar spine disc herniation. If surgery is going to be done, results will be better if the disc is removed sooner than later and before six months has passed. In agreement with the results of other studies, this study also showed that even late treatment (one to two years after the start of symptoms) offers patients some benefit by way of pain relief and improved function.

Reference: Jeffrey A. Rihn, MD, et al. Duration of Symptoms Resulting From Lumbar Disc Herniation: Effect on Treatment Outcomes. In The Journal of Bone and Joint Surgery. October 19, 2011. Vol. 93-A. No. 20. Pp. 1906-1915.