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Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study
  1. Marinella Gugliotta1,
  2. Bruno R da Costa2,
  3. Essam Dabis3,
  4. Robert Theiler3,4,
  5. Peter Jüni5,6,
  6. Stephan Reichenbach7,8,
  7. Hans Landolt1,
  8. Paul Hasler3
  1. 1Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
  2. 2Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
  3. 3Department of Rheumatology, Cantonal Hospital Aarau, Aarau, Switzerland
  4. 4Department of Rheumatology, Stadtspital Triemli, Zürich, Switzerland
  5. 5Applied Health Research Centre (AHRC), University of Toronto, Toronto, Ontario, Canada
  6. 6Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  7. 7Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
  8. 8Department of Rheumatology, Immunology and Allergology, Inselspital Bern University Hospital, Bern, Switzerland
  1. Correspondence to Professor Paul Hasler; paul.hasler{at}


Objectives Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting.

Methods A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting.

Results Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (−0.97; 95% CI −1.89 to −0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (−3.7; 95% CI −7.4 to −0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.

Conclusions Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.

  • conservative
  • hernia
  • prolapse
  • sciatica

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  • MG and BRdC contributed equally and share first authorship.

  • Contributors PH, HL, RT and MG conceived and designed the experiments; MG, ED, RT, HL and PH performed the experiments; BRdC, PJ and SR analysed the data; MG, ED, RT, HL, PH, BRdC, PJ and SR contributed to the writing of the manuscript.

  • Funding This study was funded by the Hugo and Elsa Isler Foundation, Aarau, Switzerland.

  • Competing interests PJ has received research grants to the institution from Astra Zeneca, Biotronik, Biosensors International, Eli Lilly and The Medicines Company, and serves as unpaid member of the steering group of trials funded by Astra Zeneca, Biotronik, Biosensors, St Jude Medical and The Medicines Company. The other authors report no conflict of interest.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.