- Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
Nancy E. Epstein
Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
DOI:10.4103/2152-7806.191069Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Epstein NE. Commentary on: The role of surgery for treatment of low back pain: Insights from the randomized controlled SPORT trials. Surg Neurol Int 22-Sep-2016;7:
How to cite this URL: Epstein NE. Commentary on: The role of surgery for treatment of low back pain: Insights from the randomized controlled SPORT trials. Surg Neurol Int 22-Sep-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/commentary-role-surgery-treatment-low-back-pain-insights-randomized-controlled-sport-trials/
Background:The SPORT trial database offered much useful information regarding the efficacy of surgical treatment for lumbar disc herniations, lumbar spinal stenosis, and degenerative spondylolisthesis. Data were obtained from 13 sites and included 2500 patients.
Methods:The randomized trial for lumbar disc herniations was contaminated by the immense crossover of patients from surgical (50%) to non-surgical (30%) groups. Weinstein et al. concluded that they could not claim superiority of one treatment modality over the other. Weinstein's next SPORT study on lumbar discs, performed utilizing a prospective cohort of patients undergoing lumbar disc surgery (those that would not agree to be randomized), appeared to demonstrate better outcomes with vs. without surgery.
Results:The follow-up study 8 years later again questioned the value of surgery vs. non-operative intervention. The other SPORT studies dealing with degenerative spondylolisthesis appeared to document the benefit of surgical decompression, but could not consistently substantiate the relative value of decompression alone vs. non-instrumented vs. instrumented fusion. The more recent SPORT study in 2015 on spinal stenosis treated with/without surgery indicated improvement in short term 4-year outcomes; however, the two arm-results (surgical vs. non-surgical) converged at 8 years.
Conclusions:Here, the 6 SPORT studies and short commentaries following each study indicate the pros, cons, and shortcomings of each investigation are presented. Notably, if surgeons better selected patients for surgery and avoided unnecessary procedures for “black discs alone” or pain alone, the results of the surgical intervention would likely be more clearly confirmed.
Keywords: Degenerative lumbar disease, lumbar disc, spondylolisthesis, SPORT trial
The SPORT trial database offered much useful information regarding the efficacy of surgical treatment for lumbar disc herniations, lumbar spinal stenosis, and degenerative spondylolisthesis. Data were obtained from 13 sites and included 2500 patients. The design of these studies allowed for the evaluation of large numbers of patients with reduced bias. It was of interest that the randomized trial for lumbar disc herniations was contaminated by the immense crossover of patients from surgical (50%) to non-surgical (30%) groups.[
Surgical vs. nonoperative treatment for lumbar disk herniations: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial
Weinstein et al. in 2006 evaluated surgical vs. non-surgical treatment for lumbar disc herniations utilizing the SPORT database in a randomized fashion.[
They identified 501 surgical candidates with neurodiagnostic studies confirming lumbar intervertebral disc herniations who had exhibited at least 6 weeks of radiculopathy. Patients underwent “standard open discectomy” vs. non-operative treatment. Outcomes were assessed with the Short-Form 36 (SF-36) and modified Oswestry Disability Index (ODI) at 6 weeks, 3 months, 6 months, and 1 and 2 years from the time of enrollment. Notably, there were some problems in the study design: “50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to non-operative treatment received surgery in the same period.” They found “Patients in both the surgery and the non-operative treatment groups improved substantially over a 2-year period.” However, the large numbers of patients who crossed over did not lead to a clear conclusion regarding the benefits of either treatment modality.
Comments: This study nicely highlighted the difficulty in obtaining significant data regarding the superiority of one treatment modality over another. Here, the randomized design was clearly contaminated by “crossovers” in both directions. That is, those initially choosing surgery opted for conservative care with others initially opting for conservative treatment later undergoing surgery. Therefore, although the numbers were large, and the theoretical design excellent, the authors had to clearly confront their inability to claim superiority of surgery over non-operative care. I congratulate the authors for their honesty and attempts to conduct such a complex study. It is interesting to note that the cohort study performed simultaneously appeared to indicate superiority of surgery vs. non -operative intervention for the treatment of lumbar disc herniations.
Surgical vs. non-operative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort
Weinstein et al. in 2006 evaluated the relative efficacy of diskectomy vs. non-operative care for lumbar discs. In this study, they prospectively evaluated “a cohort of potential” surgical candidates with neurodiagnostic confirmation of lumbar disc herniations treated in 13 centers in 11 states (met SPORT criteria but declined randomization).[
Comments: The study involved a large sample of patients, but was admittedly a prospective cohort study, in which there were many more patients (528 patients) in the operative vs. non-operative groups (191 patients). However, they nicely demonstrated utilizing two major patient-based outcome measures (SF-36 and ODI) that those undergoing operative intervention showed better outcomes than those managed without surgery.
Surgical versus non-operative treatment for lumbar disc herniations: four-year results for the Spine Patient Outcomes Research Trial (SPORT)
Weinstein et al. in 2008 published their concurrent, prospective, randomized, and observational cohort study looking at the 4-year outcomes of surgery versus non-operative care for lumbar discs.[
Here they concluded that at “4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than those treated non-operatively (except work status).
Commentary: This combined 4-year study involving randomized and cohort patient participants showed better outcomes for surgically treated vs. conservatively managed lumbar discs. Note that the operative modality was a “standard open procedure”: This likely accounted for the better surgical outcomes as too many of the minimally invasive techniques leave pathology behind (e.g. residual discs or insufficient disc resection contributing to recurrent discs) or cause inadvertent neural or dural injury due to inadequate exposure.
Surgical versus non-operative treatment for lumbar degenerative spondylolisthesis; four-year results in the Spine Patient Outcomes Research Trial (SPORT)
Weinstein et al. in the 2009 SPORT trial (13 centers/11 states) evaluated 4-year postoperative results of surgical versus non-operative treatment of degenerative spondylolisthesis.[
Comments: In this large SPORT study, patients with degenerative spondylolisthesis and spinal stenosis were treated with decompressive laminectomy (with or without fusion) versus non-operative care.[
Degenerative spondylolisthesis: does the fusion method influence outcome?
Abdu et al. in 2009 compared outcomes of different fusion methods to treat degenerative spondylolisthesis.[
Comments: This large SPORT database study, evaluated 380 patients variously treated with decompressive laminectomy with posterolateral in situ fusion, posterolateral instrumented fusion/pedicle screws, pedicle screws plus interbody fusion (360 degree procedures), or laminectomies alone.[
Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT)
Lurie et al. combined a randomized with a concurrent observational cohort study evaluating, over a 4-year period, outcomes of surgery vs. conservative treatment for patients with symptomatic lumbar stenosis.[
Comments: Again, the study design is a major challenge because here again those randomized to the different treatment groups demonstrated substantial crossover; only 70% randomized to surgery actually underwent surgery, whereas 52% in the non-operative groups had surgery by the 8th year of the investigation. What was of interest was the documented 4-year benefit of surgery, which appeared to dwindle/disappear by the 6th to 8th postoperative year. Because many patients were lost to follow-up, the conclusions of the study were further jeopardized.
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2. Lurie JD, Tosteson TD, Tosteson A, Abdu WA, Zhao W, Morgan TS. Long-term outcomes of lumbar spinal stenosis: Eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine. 2015. 40: 63-76
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