Invasive procedures for treating herniated discs: clinical and cost considerations

Low back injury is the most frequent cause of occupational time loss and disability. A small percentage of back injuries represent surgical disease, and great care must be taken in applying surgical therapy to this complex problem. Perhaps the most important factor in surgical management of low back injury is accurate clinical and neurodiagnostic assessment. Because of the high cost of poor surgical outcomes, diagnostic tests and surgical procedures should be chosen on the basis of efficacy rather than cost per individual case. This is because the cost of an unsatisfactory result quickly eliminates any savings accumulated by performing a less precise or less effective procedure. The best surgical outcomes appear to result from a process consisting of (1) thorough clinical evaluation, (2) electrophysiological studies in selected cases, (3) CT scanning with multiplanar reformatting and three-dimensional images as needed, and (4) individually designed surgical procedures. When used as described elsewhere, this sequence appears to best define the association between clinical and radiographic abnormalities, provide the best percentage of successful results, and potentially offer the greatest long-term economies.