gms | German Medical Science

Objective: Indication for lumbar discectomy has been the target of repeated critical discussions. Unfortunately, the quality of referral of affected patients to specialized surgeons who advise on surgical treatment thereby often receives little attention. We therefore sought to perform a prospective analysis of patients with lumbar intervertebral disc herniation (LIDH) who were referred to a single neurosurgical Universitätsklinikum in order to assess quality of referral and its possible impact on the long-term outcome and quality of life.

Methods: Between 2012 and 2013 all patients with suspected LIDH were screened and cases of other spinal diseases were excluded. Imaging and clinical parameters were recorded for all eligible patients. In addition, the attending neurosurgeon had to assess the time point of referral (too early, in time or too late) as well as the current indication for surgery (none, none yet, relative, absolute). For follow-up assessment, patients were contacted two years and 4 years after enrolment and quality of life (QoL) scores (SF36, ODI, Roland Morris Disability Scale) were obtained.

Results: 159 patients (88 male/71 female; age 50±15 years) were enrolled. Primary care physicians (38%) were accountable for most referrals. Surprisingly, patients with no indication for surgery were rare (14%) whereas a relative indication was present in 65% of cases. More than 50% of the referrals were rated “in time” but 33% of all patients were referred “too late”. In these patients, average duration of sciatia and hyp- or dysesthesia was long (30±47 and 13±12 weeks respectively). Nevertheless, success rates of conservative treatment were not significantly higher. Surgery was performed in 56% of all patients. Interestingly, complications were significantly more common when patients had been referred “too late” (p<0.05). These patients also had significantly more residual symptoms on discharge as well as a higher rate of LIDH recurrence (p<0.05 each). Nevertheless, QoL scores at the 2- and 4-years follow-up did not show significant differences between the timepoints of referral.

Conclusion: Our data suggest that one third of the patients with LIDH are referred too late for surgical evaluation although conservative treatment does not seem to be more successful. These patients have a higher risk of complications and LIDH recurrence when discectomy is performed. In the long-term, however, QoL is not significantly affected by the timepoint of referral.