Lumbar discectomy
Best Practice Guidance
How up to date is this Information?
Published January 2020 | Last reviewed September 2024
Using this guidance
The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.
Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.
Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.
Summary
A discectomy is the surgical removal of intervertebral disc material to treat the symptoms resulting from compression of one or more spinal nerve roots. This loose material, which is part of the natural degeneration of the disc with age, is often described as bulging, prolapsed, herniated or slipped, resulting in pressure on usually one, but sometimes more nerve roots. The symptoms it causes are called radiculopathy or sciatica and can include pain, tingling, pins and needles, numbness, weakness, and rarely bowel and bladder problems. As more often than not, the symptoms will settle naturally, nonoperative treatment is the preferred initial option.
Recommendation
Patients presenting with radiculopathy who show objective evidence of clinical improvement within six weeks (e.g. VAS pain scores, ODI), are more likely than not to continue improving with non-operative treatment as the natural history of most intervertebral disc herniations is favourable.
Primary care management typically includes reassurance, advice on continuation of activity with modification, weight-loss, analgesia, manual therapy and screening patients who are high risk of developing chronic pain (i.e. STaRT Back).
Persistent symptoms may warrant onward referral to spinal services for consideration of interventional pain management injections (e.g. nerve root blocks / caudal epidural injections) or surgery. In the presence of concordant MRI changes, Discectomy may be offered to patients with compressive nerve root signs and symptoms lasting three months (except in severe cases) despite best efforts with non-operative management.
Please note: This guideline is not intended to cover patients who demonstrate a deterioration in neurological function (e.g. objective weakness, sexual dysfunction, cauda equina syndrome). These patients require an urgent referral to an acute spinal centre for further evaluation and imaging, as nonoperative treatment may lead to irreversible harm.
This guidance applies to adults aged 19 years and over.
Rationale for recommendation
There remains a reasonable body of evidence to show that in carefully selected patients, lumbar discectomy may lead to a greater and quicker improvement in pain scores than in non-operatively treated patients.
In other studies however, because of the irreversible degenerative changes, surgery has not shown a benefit over non-operative treatment in mid and long-term follow-up.
Lengthy periods of ineffective non-operative care may prompt repeated emergency department attendances, issues with chronic pain, significant neurological dysfunction and time off work.
Patient information
Information for Patients
A discectomy is surgery (an operation) to remove some disc material in the spine. It should only be performed for a few clinical reasons. It is sometimes performed to treat a herniated disc (a ‘slipped disc’). But medical evidence tells us that the operation can sometimes do more harm than good. Many people’s symptoms will improve without surgery.
About the condition
A herniated disc is when the disc material that sits between the bones of your back bulges out. This usually happens as part of the natural process of the discs ageing. It can cause pressure on the nerves coming from the spine. This can cause symptoms such as pain, tingling, pins and needles, numbness, and mild weakness. These symptoms often improve over time. More serious symptoms are severe weakness and changes in the way the bowel and bladder work, which would need urgent medical attention.
What are the BENEFITS of the surgery?
If scans show there is a slipped disc and alternative treatments have not improved the symptoms over time, a discectomy may help improve the symptoms.
What are the RISKS?
A discectomy may not improve your symptoms and may make your back pain worse. Also, any surgery involves risks, including infection, bleeding, and how anaesthetics may affect you.
What are the ALTERNATIVES?
Continuing with day-to-day activities as much as possible can benefit many people. For some, losing weight, physical exercise, physiotherapy and pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.
What if you do NOTHING?
Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.
Coding
WHEN ( LEFT(Primary_Spell_Procedure,4) in ( 'V331','V332','V333','V334','V335','V336','V337','V338','V339'
,'V511','V518','V519','V583','V603')
OR ( LEFT(Primary_Spell_Procedure,4) in ('V521','V522','V525','V528','V529','V588','V589','V608','V609')
AND Any_Spell_Diagnosis LIKE '%Z993%'))
AND ( Primary_Spell_Diagnosis LIKE '%M51[01]%'
OR Primary_Spell_Diagnosis LIKE '%M54[134]%')
-- Age between 19 and 120
AND ISNULL(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120
-- Only Elective Activity
AND APCS.Admission_Method not like ('2%')
THEN '2J_Discectomy'
Exclusions
WHERE 1=1 -- Cancer Diagnosis Exclusion AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' AND Any_Spell_Diagnosis not like '%D0%' AND Any_Spell_Diagnosis not like '%D3[789]%' AND Any_Spell_Diagnosis not like '%D4[012345678]%' OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion AND apcs.Administrative_Category<>'02'
References
- Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59]
- NHS England, Trauma programme of care (2017) National Low Back and Radicular Pain Pathway.
- Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59] endorse STarT Back resource
- Lamb S, et al on behalf of the Back Skills Training Trial investigators: Back Skills Training (BeST): Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost effectiveness analysis. The Lancet 2010;375;9718,p916-923. DOI https://doi.org/10.1016/S0140-6736(09)62164-4
- Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Four-Year Results for the Spine Patient Outcomes Research Trial (SPORT). Weinstein JN et al. Spine (Phila Pa 1976). 2008 Dec 1; 33(25): 2789–2800.doi:10.1097/BRS.0b013e31818ed8f4.
- Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT). Weinstein JN et al. Spine (Phila Pa 1976). 2014 January 1; 39(1): 3–16. doi:10.1097/BRS.0000000000000088
- Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis. Chen BL et al. Clin Rehabil. 2018 Feb;32(2):146-160. doi: 10.1177/0269215517719952.
- Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomised controlled trial. Lequin MB et al. BMJ Open 2013;3:e002534. doi:10.1136/bmjopen-2012- 002534.
- Prolonged Physiotherapy versus Early Surgical Intervention in Patients with Lumbar Disk Herniation: Short-term Outcomes of Clinical Randomized Trial. Abou-Elroos DA et al. Asian Spin J 2017; 11(4):531-537. doi:10.4184/asj.2017.11.4.531.
