Surgery more effective for herniated discs than nonsurgical treatments

 A new study has revealed that for patients with herniated discs in the lower (lumbar) spine, surgery leads to greater long-term improvement in pain, functioning, and disability compared to nonsurgical treatment.

According to lead author Dr. Jon D. Lurie of Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine, carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients.

The results add to the evidence for surgical treatment of herniated discs- but also show that nonsurgical treatment can provide lasting benefits for some patients.

The researchers analyzed data from the Spine Patient Outcomes Research Trial (SPORT), one of the largest clinical trials of surgery for spinal disorders.

The current analysis included eight-year follow-up data on 1,244 patients treated at 13 spine clinics across the United States. About 500 patients were randomly assigned to surgery (a procedure called discectomy) or nonsurgical treatment, although patients were allowed to "cross over" to the other treatment.

For the remaining patients, decisions as to surgery or nonsurgical treatment were left up to the patients and their doctors. Standard measures of pain, physical functioning, and disability were compared between groups.

It was found that patients who actually underwent surgery versus nonsurgical treatment, significant differences emerged. On a 100-point pain scale, pain scores averaged about 11 points lower in the surgery group. Measures of physical functioning and disability showed similar differences.

Surgery also led to greater improvement in some additional outcomes, including the bothersomeness of sciatica symptoms, patient satisfaction, and self-rated improvement.

While average outcome scores were better with surgery, many patients had significant improvement with nonsurgical treatment. After eight years, about one-third of patients who were clinically indicated for surgery have chosen not to have operative treatment.

The study will be published in the January issue of Spine.

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Common knee surgery ineffective in study

One of the most common types of knee surgery performed in the U.S. is no more effective than fake surgery, at least for the first year, according to a new study.

The new evidence should give doctors pause before they try to repair the meniscus, which cushions the bones of the knee, according to the Finnish doctors behind the research published in the New England Journal of Medicine.

The experiment involved 146 volunteers whose knee pain appeared to be caused by wear and tear of that cushion. None of the participants had a recognized injury or osteoarthritis, both situations for which the surgery is already known to be ineffective.

After 12 months, the average improvement among the people who received real surgery and those who got "sham" surgery was essentially the same, said the research team, led by Dr. Teppo Jarvinen of University of Helsinki.

There was no significant improvement in knee pain after exercise and no sizable improvement in the likelihood that a patient would require subsequent knee surgery.

But Dr. Craig Bennett, chief of sports medicine at the University of Maryland Medical Center, cautioned that the findings should not be over-generalized. One problem, he told Reuters Health in a telephone interview, is that such "sham" surgery is, in fact, a surgical procedure with potential benefit.

People with knee pain who seem to be candidates for meniscal repair may be suffering because of debris in a swollen knee joint. "If you scope the knee (without touching the cushion), that will often help even if you don't completely address the torn meniscus issue," he said.

During an arthroscopic examination, where fluid is injected to give doctors a good view, "you're taking out the junky, thick irritating fluid that can give a lot of people their pain," he said.

During both sham and regular surgery, small holes are poked through either side of the knee, so doctors can insert instruments to examine the joint. With the surgery, known as arthroscopic partial meniscectomy, damaged and loose pieces of the cushioning material that may be out of place and interfering with the motion of the knee are trimmed away.

Because about 700,000 such surgeries are done in the U.S. each year at a cost of $4 billion, the new findings "will not be welcomed with open arms," Jarvinen predicted in a phone interview.

The study was done at five medical centers in Finland. All the volunteers had experienced knee pain for at least three months and doctors believed the problem was a tear of the medial meniscus. Nonsurgical treatment had not helped them.

Patients did now know whether they had real surgery because of the way the researchers set up the experiment. Once a doctor had used arthroscopic techniques to examine the knee, if surgery seemed appropriate, the medical team opened an envelope - with the equipment still in place - to reveal whether the patient would receive fake surgery or real surgery.

For sham surgery, the microshaver that is typically used by the surgeon for meniscus removal didn't have a blade.

The patient was not told which option was randomly chosen and neither the orthopedic surgeon nor other operating room staff were involved in further care of the patient. The patients were unable to guess whether they had received real surgery or fake surgery.

On two scales objectively measuring symptoms, there was little difference in outcomes between sham and real surgery.

But patients regarded the treatment as a success whether they received real surgery or not. Surveys showed 89 percent in the actual surgery group and 83 percent in the sham group reported improvement.

Of those who got actual surgery, 77 percent said they were satisfied with the outcome, as did 70 percent of the sham surgery group. And 93 percent who got actual surgery and 96 percent who got the sham treatment said they would be willing to repeat the procedure.

Five patients in the sham-surgery group and two who actually had surgery had such persistent problems that further surgery was required, but that difference wasn't large enough to demonstrate that the operation worked better.

Jarvien said the lesson for patients is that if you have a sore knee that's not caused by an obvious injury, "it seems we really don't have a quick fix."

"Don't feel an obligation to seek help right away," he said. "You can just treat it with the conventional bag of tricks: painkillers, icing, losing weight, or slightly moderating your activities to make it a bit more tolerable."

"Try to ride a bike, swim, to get you back to what you used to do," he said.

Bennett, however, said the situation is more complicated. He predicted that if the patients were to be followed beyond one year, younger ones would eventually show a benefit from the surgery.

"If you have a 35-year old and I leave their torn piece of meniscus tissue alone, even though they're doing better at the one-year mark than the person in whom it was cleaned up, what's the story going to be 5, 6, 7, 8, or 9 years down the road?" Bennett said. "Is that piece in a highly-active 35-year-old person going to rough up and scuff up cartilage that was originally okay?"

"Not every meniscus tear warrants surgery," he said. "There's a lot of factors that go into determining whether someone should have surgery, and you can't get much of that from this paper."

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Weight loss surgery safe, beneficial: study

Bariatric surgery results in substantial weight loss and can turn back some diseases related to obesity, a new study finds.

There is some risk of complications, but death rates appear to be lower than previously thought, researchers reported after reviewing about a decade's worth of recent data.

They were interested in updating current knowledge about the effectiveness and safety of various types of weight loss surgery, including gastric bypass, adjustable gastric banding (lap banding), vertical banded gastroplasty and sleeve gastrectomy.

These surgical procedures are used for people who are severely obese, or moderately obese with serious weight-related health problems. The last time there was a major update of bariatric surgical research was in 2003.

"Previous reviews included data from clinical trials and studies published before 2003, but because of advances in technology of bariatric surgery and accumulation of surgeons' experience, information provided in previous reviews is outdated," Su-Hsin Chang told Reuters Health in an email.

Chang is an instructor with the Division of Public Health Sciences, Department of Surgery at the Washington University School of Medicine in St. Louis, Missouri and led the new study.

"We planned to answer general questions regarding effectiveness and risks of surgical treatment of obesity and which surgical procedure is the most efficacious," Chang said.

The results were published in JAMA Surgery.

The researchers reviewed 164 studies conducted from 2003 to 2012, which included a total of 161,756 patients. On average, the patients were about 45 years old and almost 80 percent were female.

The average body mass index (BMI), a measure of weight relative to height, of patients before surgery was nearly 46. A BMI of 18.5 to 24.9 is considered normal weight and a BMI of 35 or higher is considered obese.

Patients' presurgery weight averaged 274 pounds. More than a quarter of patients had diabetes, nearly half had high blood pressure and almost 30 percent had high cholesterol. Seven percent had heart disease and 25 percent had sleep apnea.

Chang's group found that patients' BMI dropped by an average of 12 to 17 points within 5 years after surgery. The researchers also found that diabetes, high blood pressure and sleep apnea improved significantly.

Between 86 percent and 92 percent of patients with diabetes experienced remission of the disease. The same happened for about 75 percent of those with high blood pressure.

High cholesterol and heart disease were rolled back at slightly lower rates, but sleep apnea disappeared or improved dramatically in more than 90 percent of those who had it pre-surgery.

Death rates ranged from 0.08 within one month of surgery to 0.31 after 30 days. Complication rates ranged from 10 percent to 17 percent and the proportion of operations that needed to be repeated was 6 percent to 7 percent.

Gastric bypass surgeries were the most effective in terms of long-term weight loss, but the procedure had the highest complication rates. Sleeve gastrectomy was almost as effective as gastric bypass. Adjustable gastric bands (lap bands) weren't quite as effective but were the safest.

"Weight loss surgery provides substantial effects on weight loss and improves obesity-related conditions in the majority of bariatric patients, although risks of complication, reoperation and mortality exist," Chang said.

"The article is very interesting and overdue," Dr. Pratt Vemulapalli told Reuters Health in an email.

Vemulapalli is director of bariatric surgery and an associate professor of surgery at the Montefiore Medical Center of the University Hospital for the Albert Einstein College of Medicine in New York. She was not involved in the study.

"Those of us doing bariatric surgery have seen this with our own patients and in studies that have been published in the literature but this meta-analysis simply ties that data together and has wrapped the impression like a present in a neat package," she said.

Vemulapalli said there are currently about 200,000 weight loss procedures performed each year. She said the most common procedures are the gastric bypass, the sleeve gastrectomy and, to a lesser extent, the adjustable gastric band.

"The article itself was very well done, and shows that the surgeons and centers who do surgery know how to do the operations, know which patients to operate on and how to identify and treat complications," she said, "All of this makes for safer surgery."

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