AO Spine Clinical Practice Recommendations: When to Operate in Lumbar Disc Herniation

Study DesignLiterature review with consensus clinical recommendations.ObjectiveTo review key studies on surgical vs. non-operative treatment for lumbar disc herniation (LDH) and present recommendations for how the practicing clinician should use this evidence.MethodsTwo randomized controlled trials (RCTs), two RCTs with concomitant observational cohorts, one prospective study, and one retrospective study were summarized, methodologically assessed, and assigned an expert clinical recommendation.ResultsKim et al. demonstrated that selected surgical candidates who prefer to avoid surgery can achieve similar long-term outcomes with non-surgical management, although with slower recovery. Lurie et al. demonstrated surgical superiority in as-treated analyses across pain and disability up to 8 years, but substantial crossover limited intention-to-treat findings. Peul et al. showed that early surgery versus prolonged conservative management yields equivalent 1-year outcomes, with the primary benefit of faster pain relief. Bailey et al. demonstrated that for persistent sciatica (4-12 months), microdiscectomy outperforms conservative care at 6 months. Petr et al. found that in the case of acute motor deficit, surgery within 48 hours yields faster neurological recovery. Thomé et al. identified 3 days as the critical cutoff for complete recovery in moderate-to-severe deficits, with 8 days applicable for mild deficits.ConclusionsThe evidence suggests that, for patients without motor deficits, symptom duration, severity, and patient preference should drive treatment selection, with increasing benefit of surgery as symptom duration grows. For patients with motor deficits, decompression within 3 days should be the goal for moderate-to-severe paresis to maximize the likelihood of complete neurological recovery.