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Neurospine Search


Kim: Surgical Timing in Lumbar Disc Herniation Surgery
In response to article titled “Timing of Surgery in Tubular Microdiscectomy for Lumbar Disc Herniation and Its Effect on Functional Impairment Outcomes,” [1] lumbar disc herniation (LDH) is a major spinal degenerative disease. The treatments are largely categorized as exercise, medication, intervention and surgery. Pain is the major symptom in most cases and it could be controlled with relevant treatments. Nonsurgical treatment is successful for majority of patients, but surgery is required for medically intractable cases. The treatment strategy looks simple. However, it is not straightforward. Surgeons operate LDH when nonsurgical treatment fails or major neurological symptom persisted over 6 weeks and the surgical outcomes are satisfactory in more than 90% of cases [2]. However, 6 weeks of conservative period is subject to make misunderstanding among health care providers, physicians and patients and limits physician (surgeon)’s discretionary decision.
The surgical techniques could be broken down into standard open discectomy, tubular retractor assisted discectomy or endoscopic surgery and the surgical outcomes of those techniques did not seem to be different based on previous studies [3-6]. However, the efficacy of surgery may be mostly evident only for a short-term follow-up period (< 2 years) [7]. This may be one of major reasons for the patients to be reluctant to get surgery when it is really necessary. However, more often than not, we encounter patients ended up in suffering from a chronic pain, even after successful removal of LDH by surgery. There are many factors influencing on the outcomes, such as duration of symptom, accompanying neurological deficit, psychological factor, occupation, and so on [8]. If we failed to address LDH in a timely manner, the chance for a successful outcome would go down either with surgery or nonsurgical treatment [9]. Therefore, we have to figure out how to address LDH relevantly, especially with surgery [2,7]. In this regards, this study is meaningful in adding information regarding the issue of “When should we operate on LDH?” I appreciate the authors’ effort. However, the evidence level of this study would be level IV, considering retrospective subgroup analysis for prospectively collected data. In addition, the method to assess duration of symptom may subject to recall bias. I hope the readers to acknowledge the limitations of this study.


1. Siccoli A, de Wispelaere MP, Schröder ML, et al. Timing of surgery in tubular microdiscectomy for lumbar disc herniation and its effect on functional impairment outcomes. Neurospine 2020 17:204-12.
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2. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2008 33:2789-800.
crossref pmid pmc
3. Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976) 2008 33:931-9.
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4. Qin R, Liu B, Hao J, et al. Percutaneous endoscopic lumbar discectomy versus posterior open lumbar microdiscectomy for the treatment of symptomatic lumbar disc herniation: a systemic review and meta-analysis. World Neurosurg 2018 120:352-62.
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5. Birkenmaier C, Komp M, Leu HF, et al. The current state of endoscopic disc surgery: review of controlled studies comparing full-endoscopic procedures for disc herniations to standard procedures. Pain Physician 2013 16:335-44.
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6. Butler AJ, Alam M, Wiley K, et al. Endoscopic lumbar surgery: the state of the art in 2019. Neurospine 2019 16:15-23.
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7. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006 296:2441-50.
crossref pmid pmc
8. Lurie JD, Henderson ER, McDonough CM, et al. Effect of expectations on treatment outcome for lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 2016 41:803-9.
crossref pmid pmc
9. Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 2011 93:1906-14.
crossref pmid pmc

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