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Diskectomy candidates with at least 6 weeks of sciatica and confirmatory imaging were enrolled in a randomized or observational cohort.This study sought to determine: (1) whether diskectomy resulted in greater improvement in back pain than nonoperative treatment, and (2) whether herniation location and morphology affected back pain outcomes.Previous studies have reported that lumbar diskectomy is less successful for relief of back pain than leg pain and patients with central disc herniations or protrusions have worse outcomes.Patients underwent diskectomy or received “usual” nonoperative care. Data from the randomized cohort and observational cohort were combined in an as-treated analysis. Low back pain was recorded on a 0 to 6 point scale, and changes in low back pain were compared between the surgical and nonoperative treatment groups. The effects of herniation location and morphology on back pain outcomes were determined.The combined analysis included 1191 patients with 775 undergoing surgery within 2 years, whereas 416 remained nonoperative. Overall, leg pain improved more than back pain in both treatment groups. Back pain improved in both surgical and nonoperative patients, but surgical patients improved significantly more (treatment effect favoring surgery −0.9 at 3 months, −0.5 at 2 years, P < 0.001). Patients who underwent surgery were more likely to report no back pain than nonoperative patients at each follow-up period (28.0% vs. 12.0% at 3 months, P < 0.001, 25.5% vs. 17.6% at 2 years, P = 0.009). At baseline, central herniations were associated with more severe back pain than more lateral herniations (4.3 vs. 3.9, P = 0.012). Patients with central herniations and protrusionshad a beneficial treatment effect from surgery similar to the overall surgical group.Diskectomy resulted in greater improvement in back pain than nonoperative treatment, and this difference was maintained at 2 years for all herniation locations and morphologies.