Treating Lumbar Disc Sciatica on an outpatient basis
Each year, approximately 7 million Americans will join the 75 million fellow Americans who have experienced low back pain. These individuals will collectively spend over $5 billion on tests and treatments for their back pain, with around 200,000 of them undergoing lumbar disc operations.
The significant cost burden associated with back pain treatment has resulted in a major restructuring of the healthcare industry, focusing on shifting from inpatient to outpatient treatments whenever feasible.
While most cases of “low-back strains” can be effectively treated on an outpatient basis, the management of lumbar disc derangements accompanied by sciatic radiculopathy and the potential risks of paralysis or persistent pain have established a standard where admission to the hospital for two to three weeks of bed rest and conservative treatment is considered the gold standard.
This standard serves as a benchmark against which the effectiveness of conservative treatments should be evaluated before considering surgical intervention.
A retrospective evaluation was reported by literature on 50 patients who had received ambulatory care for lumbar disc-related sciatica. These patients were selected randomly based on their diagnosis of lumbar disc with sciatic radiculopathy in the L-5 or S-1 distribution.
After being discharged from the ambulatory care facility, they were followed for a minimum of one to three years. A reevaluation of these patients took place four to seven years later.
The treatment program implemented a comprehensive approach specifically designed for managing arthritis, back pain, and related rheumatologic conditions in an ambulatory care setting.
Within a cohort of 47 patients presenting clinical signs and symptoms indicative of acute to subacute lumbar disc with radiculopathy at the L-5 or S-i level, 39 patients experienced effective management through an outpatient treatment program.
During the initial evaluation, these individuals required bed rest or restricted activity to control their symptoms, leading to their categorization into either phase I (bed rest) or phase II (part-time activity).
During the first follow-up, which took place one to three years after their discharge, it was observed that a majority of the patients demonstrated progress. Out of the 39 patients, 37 had transitioned to phase III, involving full-time sedentary work and home activity, or phase IV, allowing them to engage in vigorous sports.
This indicates an improvement in their functional abilities over time. Positive outcome in terms of their condition and overall functionality were achieved.
Furthermore, it is important to mention that among the patients, one individual underwent chymopapain nucleolysis, and seven patients chose to undergo laminectomies as treatment options. However, it is notable that two patients did not experience any improvement and decided not to proceed with the recommended operation.
The average duration of treatment for the 39 patients who did not undergo surgery was 115 ± 76 days. Excluding the patient with chronic recurrent symptoms who ultimately underwent a laminectomy, the average time from the initial visit to surgical referral was 23 days, with a range of 10 to 36 days.
Among the eight patients who eventually needed either chymopapain or a surgical operation, their treatment at the center before referral lasted an average of 38 days, ranging from 10 to 145 days.
The average expense associated with comprehensive management of the nonsurgical cases at the center, encompassing physicians’ fees, physical and occupational therapy, necessary equipment and supplies, as well as laboratory and x-ray examinations (excluding occasional EMG or CT scans performed specifically for patients recommended for surgical intervention), amounted to $1,062.
On the other hand, the average cost for the eight patients referred for surgery prior to their referral was $633. Thus, it can be inferred that the total expenditure for outpatient treatment remained below the prevailing daily bed charges for approximately one and a half to two days of hospitalization.
A longer treatment duration was observed for nine patients who had been admitted to the hospital within six months prior to commencing treatment at the center. However, this extended duration did not have any impact on the eventual favorable outcomes in these cases.
Factors such as previous accidents, severity of initial symptoms, chronicity, gender, the use of braces and corsets, as well as the use of transcutaneous nerve stimulators, were found to be insignificant in relation to the treatment outcomes.
The majority of patients with low back pain and lumbar disc disease accompanied by sciatica tend to have favorable outcomes without surgery. Conservative management is preferred due to the limited effectiveness of surgery, except in cases of cauda equina compression or rapidly progressing leg weakness.
Bed rest is a key component of successful conservative treatment, although the high cost of hospital care makes it financially burdensome. Surgical intervention offers limited benefits in terms of preventing recurrence or minimizing disability. Only a small percentage of back pain cases require surgery, representing a fraction of the overall cases requiring treatment.
Improvements in home treatment strategies make outpatient management of patients with lumbar disc derangement and sciatica increasingly attractive. In our study, the duration of symptoms before the initial evaluation was considered, with surgical cases averaging 9.5 months and conservatively treated cases averaging 5.5 months.
Home treatment strategies include detailed instructions on activities, lumbosacral corsets, cold-pack therapy, and necessary equipment. Close follow-up and modifications to therapy play a crucial role in achieving successful outcomes. However, inadequate patient education regarding activities and exercise may contribute to higher early treatment failure rates in conservative approaches.
Bed rest with bathroom privileges is typically required for less than two weeks in most of our cases. Over the course of the first month or two, activities are gradually resumed from phase II to phase III.
Once phase III activities and exercises are successfully achieved, further conditioning for more strenuous athletic pursuits begins, which may involve supervised exercise progression for specific sports lasting two to three months.
Patient education and adherence to the treatment program, particularly in terms of activity level and exercise conditioning, have a significant impact on the outcome. During the initial follow-up period (one to three years after discharge), 83% of the patients were still continuing their exercises.
In the four- to seven-year follow-up, these patients either continued with their discharge exercise program or adopted another suitable regimen, such as yoga, to maintain their physical well-being.
In a study reported by literature, certain patients who received conservative treatment found relief and avoided surgery through the administration of one to four epidural steroid injections.
However, when it came to patients who required surgery, prior injections did not yield any positive results. Furthermore, one patient experienced a recurrence of symptoms and necessitated a second course of treatment.
Refractory pain at rest or with limited activity and a positive straight-leg-raising test at less than 45 degrees were indicators of poor prognosis and the need for interventions such as epidural blocks or surgery.
Among the surgical group, 4 out of 8 patients experienced both sensory and motor deficits, whereas this was observed in 13 out of 39 patients in the conservatively treated group. The severity of initial deficits did not have a negative impact on the outcome of conservatively treated cases.
In a study of 31 patients with back pain, 4 showed no improvement or experienced recurrent episodes. One patient had chronic pain, while another needed a special device for pain control. One patient underwent a procedure and had a year-long recovery.
Overall, 88% of the patients had successful outcomes, which is better than surgical treatment for similar conditions. This questions the need for surgery as a preventive measure for recurring back problems.
The average time for patients to return to work after surgical treatment for lumbar disc disease in a Kaiser Permanente study was 84.3 days, while our patients had a shorter average return to work time of 17.3 days.
However, our patients took longer (115 + 76 days) to reach their maximum level of function before being discharged. These differences may be due to patient demographics and the close supervision provided until patients achieve their peak athletic capability.
Non-surgical treatment for lumbar disc disease accompanied by sciatica has demonstrated success rates ranging from 8% to 28%. In our investigation, 79% of patients who received care as outpatients at a specialized center were able to resume their normal or athletic activities.
Surgical intervention was necessary for only 15% of these patients. Outpatient management has proven to be just as effective as hospital-based treatment or surgery, while also offering the advantage of reduced expenses.