Optimal Duration of Conservative Management Prior to Surgery for Cervical and Lumbar Radiculopathy: A Literature Review
25 April 2014
23 June 2014
28 August 2014 (eFirst)
Study Design Literature review.
Objective Since the 1970s, spine surgeons have commonly required 6 weeks of failed conservative treatment prior to considering surgical intervention for various spinal pathologies. It is unclear, however, if this standard has been validated in the literature. The authors review the natural history, outcomes, and cost-effectiveness studies relating to the current standard of 6 weeks of nonoperative care prior to surgery for patients with spinal pathologies.
Methods A systematic Medline search from 1953 to 2013 was performed to identify natural history, outcomes, and cost-effectiveness studies relating to the optimal period of conservative management prior to surgical intervention for both cervical and lumbar radiculopathy. Demographic information, operative indications, and clinical outcomes are reviewed for each study.
Results A total of 5,719 studies were identified; of these, 13 studies were selected for inclusion. Natural history studies demonstrated that 88% of patients with cervical radiculopathy and 70% of patients with lumbar radiculopathy showed improvement within 4 weeks following onset of symptoms. Outcomes and cost-effectiveness studies supported surgical intervention within 8 weeks of symptom onset for both cervical and lumbar radiculopathy.
Conclusions There are limited studies supporting any optimal duration of conservative treatment prior to surgery for cervical and lumbar radiculopathy. Therefore, evidence-based conclusions cannot be made. Based on the available literature, we suggest that an optimal timing for surgery following cervical radiculopathy is within 8 weeks of onset of symptoms. A shorter period of 4 weeks may be appropriate based on natural history studies. Additionally, we found that optimal timing for surgery following lumbar radiculopathy is between 4 and 8 weeks. A prospective study is needed to explicitly identify the optimal duration of conservative therapy prior to surgery so that costs may be reduced and patient outcomes improved.
- 1 Lunsford LD, Bissonette DJ, Jannetta PJ, Sheptak PE, Zorub DS. Anterior surgery for cervical disc disease. Part 1: Treatment of lateral cervical disc herniation in 253 cases. J Neurosurg 1980; 53 (1) 1-11
- 2 Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994; 117 (Pt 2) 325-335
- 3 Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med 2005; 353 (4) 392-399
- 4 Spurling RG, Segerberg LH. Lateral intervertebral disk lesions in the lower cervical region. J Am Med Assoc 1953; 151 (5) 354-359
- 5 Räsänen P, Ohman J, Sintonen H , et al. Cost-utility analysis of routine neurosurgical spinal surgery. J Neurosurg Spine 2006; 5 (3) 204-209
- 6 Younes M, Béjia I, Aguir Z , et al. Prevalence and risk factors of disk-related sciatica in an urban population in Tunisia. Joint Bone Spine 2006; 73 (5) 538-542
- 7 Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA. Lack of effectiveness of bed rest for sciatica. N Engl J Med 1999; 340 (6) 418-423
- 8 Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine (Phila Pa 1976) 1993; 18 (11) 1433-1438
- 9 Hakelius A. Prognosis in sciatica. A clinical follow-up of surgical and non-surgical treatment. Acta Orthop Scand Suppl 1970; 129: 1-76
- 10 Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 1983; 8 (2) 131-140
- 11 Rothoerl RD, Woertgen C, Brawanski A. When should conservative treatment for lumbar disc herniation be ceased and surgery considered?. Neurosurg Rev 2002; 25 (3) 162-165
- 12 Hurme M, Alaranta H. Factors predicting the result of surgery for lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 1987; 12 (9) 933-938
- 13 Fisher C, Noonan V, Bishop P , et al. Outcome evaluation of the operative management of lumbar disc herniation causing sciatica. J Neurosurg 2004; 100 (4, Suppl Spine): 317-324
- 14 Akagi R, Aoki Y, Ikeda Y , et al. Comparison of early and late surgical intervention for lumbar disc herniation: is earlier better?. J Orthop Sci 2010; 15 (3) 294-298
- 15 Peul WC, van Houwelingen HC, van den Hout WB , et al; Leiden-The Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356 (22) 2245-2256
- 16 Folman Y, Shabat S, Catz A, Gepstein R. Late results of surgery for herniated lumbar disk as related to duration of preoperative symptoms and type of herniation. Surg Neurol 2008; 70 (4) 398-401 , discussion 401–402
- 17 Nakagawa H, Kamimura M, Takahara K , et al. Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation. J Clin Neurosci 2007; 14 (2) 104-109
- 18 Jönsson B, Strömqvist B. Clinical appearance of contained and noncontained lumbar disc herniation. J Spinal Disord 1996; 9 (1) 32-38
- 19 Vroomen PCAJ, de Krom MCTFM, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 2002; 52 (475) 119-123
- 20 van den Hout WB, Peul WC, Koes BW, Brand R, Kievit J, Thomeer RT. Leiden-The Hague Spine Intervention Prognostic Study Group. Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ 2008; 336 (7657) 1351-1354
- 21 Murphy MG, Gado M. Anterior cervical discectomy without interbody bone graft. J Neurosurg 1972; 37 (1) 71-74
- 22 Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine (Phila Pa 1976) 1996; 21 )24, Suppl): 2S-9S
- 23 Hidalgo-Ovejero AM, Garcia-Mata S, Martinez-Grande M. Natural history and nonoperative treatment of lumbar disc herniation. Spine (Phila Pa 1976) 1998; 23 (4) 508-510
- 24 Luijsterburg PAJ, Verhagen AP, Braak S, Avezaat CJ, Koes BW. Do neurosurgeons subscribe to the guideline lumbosacral radicular syndrome?. Clin Neurol Neurosurg 2004; 106 (4) 313-317
- 25 Vader JP, Porchet F, Larequi-Lauber T, Dubois RW, Burnand B. Appropriateness of surgery for sciatica: reliability of guidelines from expert panels. Spine (Phila Pa 1976) 2000; 25 (14) 1831-1836
- 26 Aetna Clinical Policy Bulle tin. Spinal Surgery: Laminectomy and Fusion; 2013. Available at: http://www.aetna.com/cpb/medical/data/700_799/0743.html
- 27 BlueCross BlueShield of North Carolina Corporate Medical Policy; 2012. Available at: https://www.bcbsri.com/sites/default/files/polices/LumbarFusion.pdf
- 28 United HealthCare Medical Policy Update Bulletin; 2012. Available at: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policy%20Update%20Bulletins/Policy%20Update%20Bulletins/Medical_Policy_Update_Bulletin_March_2012.pdf
- 29 Daffner SD, Hymanson HJ, Wang JC. Cost and use of conservative management of lumbar disc herniation before surgical discectomy. Spine J 2010; 10 (6) 463-468