Examination of quality of life and economic benefit with early lumbar microdiscectomy: A Pilot Study

Examination of quality of life and economic benefit with early lumbar microdiscectomy: A Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Examination of quality of life and economic benefit with early lumbar microdiscectomy: A Pilot Study Jack Horan, Lena Mary Houlihan, Paula Corr, Deirdre Nolan, Mohammed Ben Husien This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6263561/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Lumbar microdiscectomy is a surgical intervention which improves radiculopathy with lower back pain and quality of life. The health economic benefit of completing surgery in a timely manner has not been explored in depth. We ask to question is early surgery superior in quality of life when compared to late surgery? Methods A prospective database of patients who met the inclusion criteria was used to garner data on patient waiting times. Telephone interviews were completed detailing various outcome measures of the core outcome measures index (COMI) questionnaire post-operatively. Surgery was early (less than 12 months) or late (more than 12 months). Results Post-operative ‘Sciatica severity’ shows a statistically significantly greater value in sciatica severity among those presenting to surgery greater than one year (score of 3.9) compared to those presenting to surgery less than one year (score of 1.8). ‘Rest of life symptom satisfaction’ shows statistically significant differences between the surgical wait-time groups, with those operated on within one year more likely to be very satisfied than those after one year. Hospital length of stay nears a statistically significant difference for those operated on within one year(median 3 days) compared to those operated on after one year(median 2 days), but this does not reach statistical significance. Conclusion Regardless of cost, it is apparent that patient-related outcomes are superior in candidates operated on within one year. Poorer quality of life outcomes highlight how a successful operative intervention is deemed less effective due to delays outside of the surgeon’s control. Our results highlight that these operations should be completed in a timely manner to ensure the patient is receiving the highest standard of care and minimise the likelihood of representation. Figures Figure 1 1. Introduction Lumbar discectomy is a common surgical treatment for a prolapsed disc leading to radicular leg pain or sciatica [ 1 ]. In 75% of patients with leg pain, symptoms will resolve with conservative treatment by 3 months [ 2 ]. In patients who do not improve within that time period, surgical treatment has been shown to be effective. At 1 year follow-up, surgical treatment was superior to conservative treatment in pain outcomes. This benefit became less pronounced, as follow-up approached 10 years [ 3 ]. Surgery has a faster resolution of leg pain, return to normal activities and recovery when compared to conservative treatment [ 4 ]. Chronic pain back and leg pain from degenerative spine disease can significantly impact patient’s quality of life. The pain can prevent participation in normal activities and can lead to social isolation and patients being unable to work [ 5 ]. Low mood and depressive symptoms may be seen pre-operatively before surgery in degenerative spine disease [ 6 ]. Post-operative improvement in pain can have a positive impact on depressive symptoms [ 7 ]. A Swedish study found that in patients undergoing surgery for lumbar disc disease, health related quality of life (QOL) improved post-operatively. However, in patients with symptoms of leg pain for greater than 6 months, the level of improvement in QOL was reduced [ 8 , 9 ]. The optimal timing for lumbar microdiscectomy for radicular pain (and not emergent cauda equina syndrome or with neurological deficit) is debatable, with conflicting results in the literature. There remains a debate on if there should be a time-frame within which these surgeries should be performed, and what that time frame is [ 4 , 9 – 15 ]. A systematic review proposed that surgery should be performed within 6 months as surgery after 6 months was associated with poorer outcomes [ 14 ]. The aim of the study was to assess if performing lumbar discectomies for radicular pain without neurological deficit earlier, lead to improved quality of life outcomes. The health economic benefit of completing surgery in a timely manner has not been explored in depth and this is another focus of the study. 2. Materials and methods A single centre retrospective cohort study reviewing patient demographics and outcomes with the internationally validated Core Outcome Measures Index (COMI) assessment [ 16 ]. Retrospective collection of patient surgical wait times and length of stay was gathered. The time parameter was split into waitlisted for surgery for less than one year or more than one year. All patients who underwent primary elective lumbar microdiscectomy in [BLINDED] from January 2020 - December 2021 for radiculopathy were included. Patient symptoms included back pain, leg pain or sensory deficits. All patients had a magnetic resonance imaging (MRI) scan confirming a prolapsed disc with nerve root compression. Exclusion criteria included emergency cauda equina syndrome surgery or patients with a footdrop or neurological deficit. A prospective database of patients who met the inclusion criteria was used to garner data on patient waiting times. Telephone interviews were completed detailing various outcome measures of the COMI questionnaire post-operatively. Length of stay and complications were recorded. Ethical approval was granted by the Hospital’s Review Board. 2.1 Outcomes The main outcome of the study was to compare quality of life outcome differences between patients presenting to surgery less than versus greater than one year. We wanted to address the following questions: (1) Does the length of the presentation to surgery have an influence on outcome measures? (2) Does the length of presentation to surgery have an influence on post-operative length of stay? (3) Does the length of presentation to surgery have an influence on cost, i.e. cost of length of stay? 2.2 Core Outcome Measures Index (COMI) The COMI and the variables measured are shown in Fig. 1 . 2.3 Statistical Analysis Stata version MP15 was used for statistical analysis. P -values associated with the categorical dependent variables are from ordered logistic regressions. P -values associated with skewed continuous variables are from Mann-Whitney U-tests for differences of medians, and p -values associated with continuous variables not exhibiting skew are from t-tests. A P- value < 0.05 was considered statistically significant. 3. Results 64 patients were eligible for inclusion to the study. 38 respondents to telephone interview were included in the final analysis. 20 patients (52.6%) underwent microdiscectomy within one year of being listed for surgery. 18 patients (47.4%) underwent microdiscectomy more than one year of being listed for surgery. 3.1 Pre-operative symptoms Back pain was the most common symptom in patients waitlisted for more than one year (38.9%). Buttock/leg pain was the most common symptom in patients waiting less than one year for surgery (50%) (Table 1) 3.2 Post-operative sciatica severity ‘Sciatica severity’ is tested as a difference in medians, a t-test of difference in means shows a statistically significantly greater value in sciatica severity among those presenting to surgery greater than one year (score of 3.9) compared to those presenting to surgery less than one year (score of 1.8). The test for difference in medians should be reported, and this nears statistical significance (Table 1). 3.3 Post-operative work interference Overall in the study 65.8% of patients had no or minimal work interference. 5 and 5.6% of patients in the less than and more than one year group respectively had substantial work interference post-operatively. 10% of patients in the group less than one year had rated work interference ‘extremely’, in comparison to 22.2% of patients who waited for more than one year for surgery (Table 1) 3.4 Post-operative rest of life symptom satisfaction ‘Rest of life symptom satisfaction’ shows statistically significant differences between the surgical presentation time groups, with those presenting within one year more likely to be very satisfied than those presenting for surgery after one year, and those presenting within one year less likely to be very dissatisfied than those presenting for surgery after one year (Table 1) 3.5 Work Restriction The number of patients that had no work restrictions post operatively between surgical wait groups of less than or more than one year was very similar (40% versus 38.9%). The number of patients with greater than 21 work days restriction was slightly higher in the greater than one year group at 27.8% compared to 20% in the less than one year group (Table 2) however this did not reach statistical significance. 3.6 Occupation Restriction The number of patients with no occupation restriction and greater than 21 days restriction was the same between less than one year and more than one year (55% versus 55.6%; 25% versus 27.8%) (Table 2) 3.7 Satisfaction with care Overall 73.7% of patients were very satisfied with their care. 70% and 77.8% were very satisfied in less than one year versus more than one year wait. 10% of patients in the less than one year group were somewhat or very dissatisfied with no patients in the greater than one year group dissatisfied with care (Table 3). 3.8 Help of operative intervention Overall 92.1% of patients felt the operation helped a little to helped greatly. Only 2.6% of respondents felt that the operation made things worse (Table 3). 3.9 Hospital length of stay (days) Hospital length of stay nears a statistically significant difference for those presenting for surgery within one year (median 3 days) compared to those presenting for surgery after one year (median 2 days) (Table 3). 3.10 Complications The overall complication rate was 5.6%. 10% (2 patients) experienced a cerebrospinal fluid leak in the surgery less than one year group. No other complications were seen (Table 4) 3.11 Redo surgery Among the n=5 patients who required a re-do surgery, their average LOS is 5 days, for an average cost of €7,500.00. This is statistically significantly greater (mean LOS=5 days, p=.007) than patients who did not have a re-do surgery (mean LOS=2.4 days) (Table 4) 3.12 Cost analysis Patients who present for surgery in less than one year stay in the hospital longer and therefore cost more than patients who present for surgery after one year. These differences in means and medians near statistical significance ( p = 0.053). Median cost overall was €3,000. The surgery less than one year had a median cost of €4,500 versus the group who had surgery longer than one year had a median of €3,000 (Table 5). 4. Discussion This study is a single centre retrospective cohort study reviewing quality of life outcomes in patients undergoing elective lumbar discectomy for radiculopathy with no neurological deficits. Two groups were included and compared. The first group of patients had surgery less than one year following listing for surgery and were compared to patients who had surgery over one year following wait listing. Patients operated on within one year had significantly better ‘rest of life symptom satisfaction’ and post-operative ‘sciatica severity’ scores than patients who waited longer than one year for surgery. Lumbar disc disease and its clinical sequalae is associated with an increased incidence of comorbid medical conditions and poor health-related quality of life [ 17 ]. Many studies comparing lumbar discectomy versus conservative management are for acute disc prolapse, for symptoms ongoing for up to 3 months. These studies have shown surgery is favourable in reducing short-term pain when compared to conservative treatment. However, at one year follow-up, pain rates were no different between surgical and conservatively managed groups [ 3 , 4 , 18 ]. The optimal timing for lumbar microdiscectomy for radicular pain (and not emergent cauda equina syndrome or with neurological deficit) with regards to pain and quality of life outcomes is up for debate as results in the literature are conflicting. The optimal time to surgery for elective microdisectomy has a wide range, going from as little as two months post symptoms up to 12 months post symptoms with some studies reporting an upper limit of 6 months [ 4 , 9 – 15 ]. Siccoli et al. [ 12 ] included 372 patients who underwent primary tubular microdiscectomy for radicular pain. Their primary outcome was disability as measured on the Oswestry Disability Index (ODI), with a definition of minimal clinically important difference (MCID) as a 30% decrease or more in ODI from baseline to 12 months post-operatively. They have shown that better functional outcomes were seen when patients underwent surgery between 14–22 weeks after symptoms began. Lower TTS gave a greater chance of a better functional outcome, and propose surgery should be performed no later than 22 weeks following symptom onset. Siccoli et al. [ 11 ] performed another analysis on the same patient group with regards to pain outcome and the timing of surgery. Similar methodology was used, with a 30% reduction in pain scores on a numerical scale being defined as a MCID. Surgery within 24 weeks showed an 80% or higher chance of a positive pain outcome. Beyond 24 weeks, the likelihood of a favourable pain outcome was reduced [ 11 ]. Bailey et al. [ 13 ] performed a randomised control trial in 128 patients with sciatica for longer than 4 months. Surgical treatment was superior in leg pain outcomes at 6 months, when compared to conservative management. A systematic review that included 11 studies concluded that symptom presence beyond 6 months was likely to lead to reduced recovery following surgical intervention. Within this analysis, 4 studies compared time periods less than 10 or 12 months of symptoms and greater than 10 or 12 months of symptoms pre-operatively. These studies found that pain and or disability was worse in the groups that had symptoms for greater than 10 or 12 months [ 9 ]. A meta-analysis from 2014 including 21 studies showed that the presence of leg pain for a prolonged period had a higher risk of worse outcomes following lumbar disc surgery. As the studies included were heterogeneous in design, a guideline of surgery from 2–12 months was proposed. They did note that surgery performed within 6 months was most likely to lead to a favourable outcome [ 14 ]. These results were similar in our study, with both pain and rest of life symptom satisfaction significantly worse in the group that waited longer than one year for surgery. In contrast, two studies investigating the timing of surgery in lumbar discectomy did not find any difference in outcomes based on timing of surgery. Gurung et al [ 10 ] included 87 patients in their retrospective analysis comparing timing of lumbar microdiscectomy. They grouped patients into three distinct groups, time to surgery less than 6 months, 6 months to 12 months and greater than 12 months. Outcomes were pain measured on the visual analogue scale (VAS) and disability on ODI. Minimal clinically important difference from baseline to 33% for pain and 30% for disability were considered significant. In all patients an improvement on pain and function was observed. They did not observe a significant difference in outcomes of pain or disability at 6 months post-operatively. In an analysis of 283 patients that compared surgery to conservative treatment, early surgery lead to a faster reduction in pain when compared to conservative treatment. However, at 12 months there was no difference in pain between the two groups [ 4 ]. Dandurand et al [ 19 ] compared early (less than 60 days following consent) to late surgery (more than 60 days following consent) for elective lumbar discectomy on a cost-comparison analysis in Canada. 493 patients were included, 272 in the early group and 221 patients in the late group respectively. Early surgery conferred an estimated saving of $ 11,234.89 per patient. This was attributed to lower work absenteeism in this group. In people working at time of consenting, there were significantly lower sick days from work overall in the early compared to the late group. No difference in time to return to work or in the return to work rates were seen between groups. Initially, the early group had higher costs due to more emergency room visits, physiotherapy appointments and imaging. This can be explained by their higher pain scores and disability. Post-operatively, a significantly higher proportion of the early group met the MCID for leg pain at 3 months (84.0% vs 75.9%, p < 0.040). A Dutch study across 9 hospitals found that early surgery (within 12 weeks of symptom onset) for sciatica compared to prolonged conservative treatment for 6 months is cost-effective. The early surgical group cost €1819 more than the conservative group. The cost of surgery made up the majority of the difference. Following surgery, initially patients had a period of time that they were unable to work. However, the surgery group had less days off work during the remainder of the year when compared to the conservative group. This study concluded early surgery on a cost and quality adjusted life years (QALY) basis was cost effective [ 20 ]. In patients with chronic sciatica (symptoms 4–12 months), surgery is cost effective when compared to conservative management. Even in patients that crossed over to the surgical arm of the study, the cost-effectiveness remained. The authors propose reasons that surgery had a favourable cost-utility estimate is that there was low crossover past 6 months and as surgery occurred relatively quickly, there were fewer peri-operative costs [ 21 ]. As explained above, multiple trials have shown that earlier surgery leads to faster resolution of symptoms, and the longer symptoms are present, the less likely a favourable outcome will be achieved [ 9 , 13 ]. The presence of back pain limiting work is a severe burden for patients and society. Getting patients back to work following surgery is an important metric for surgical outcomes [ 22 ]. Khan et al [ 23 ] performed a retrospective analysis on a national spine registry in the United States. This study included over 12,000 patients and investigated factors that impacted return to work in patients undergoing elective lumbar spine surgery. An independent risk factor in failure to return to work was the presence of symptoms for more than 3 months. While conflicting reports exist on the significance of timing of surgery, our study reflected the evidence of the prevailing majority of studies. The evidence and benefits for earlier surgery are growing and has been repeated in multiple studies. It does stand to reason that functional outcomes are improved by reduced times to surgery. Patients waiting for surgery are often in pain and may be out of work. With the evidence that surgery allows a faster reduction in pain in the short-term, this may translate into the improved QOL that is seen in patients who have surgery in a shorter time-frame, short-term pain is improved and are back at work [ 4 ]. Based on our data and published data, it would be reasonable to propose that early surgical intervention in appropriate candidates may provide superior patient outcomes and minimises the associated socioeconomic sequalae for both the patient and healthcare system. This rudimentary analysis is predominantly psychosocial and does not consider factors such as patient comorbidities and deeper level cost such as patient loss of income, medications regimes and adjunct therapies such as physical therapy. We propose a maximum waiting time of 6 months for lumbar discectomy for sciatica. This time limit should be non-negotiable, to give the best chance of a positive outcome for patients. Limitations of this study include the retrospective nature of the study, the small sample size and the low response to our telephone interview (59%). A prospective study where patients pre-operative symptoms and quality of life outcomes may allow a more robust study and any conclusions that may be drawn from the study. There were also variation in timings between surgery and post-operative interview. A randomised control trial comparing early to delayed surgery would be ideal in answering the question if early surgery has improved pain and functional outcomes. This study may be difficult to enrol patients, with the fact that half of the patients will be listed for surgery but will be told that they won’t have it at the earliest for 6 months. Patients enrolling in a surgical trial may want surgery to be performed as soon as possible once they agree and may not enrol if they are part of the delayed group. 5. Conclusion Regardless of cost, it is apparent that patient-related outcomes are superior in candidates operated on within one year. Poorer quality of life outcomes highlight how a successful operative intervention is deemed less effective due to delays outside of the surgeon’s control. Our results highlight that these operations should be completed in a timely manner to ensure the patient is receiving the highest standard of care and minimise the likelihood of representation. In line with international practice, we propose a maximum wait time of 6 months for an elective microdiscectomy for radicular pain. Declarations Declaration of competing interest The authors confirm that they have no competing financial interest or personal relationships that could influenced the findings reported in this paper. Author Contribution J.H, L.M.H and M.B.H - wrote main manuscript textJ.H, L.M.H, P.C, D.N - data collectionL.M.H - data analysisL.M.H and M.B.H - study conceptionAll authors reviewed the manuscript References Ropper AH, Zafonte RD (2015) Sciatica. N Engl J Med 372:1240-1248. doi: 10.1056/NEJMra1410151 Vroomen PC, de Krom MC, Knottnerus JA (2002) Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 52:119-123 Weber H (1983) Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 8:131-140 Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW, Group L-THSIPS (2008) Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336:1355-1358. doi: 10.1136/bmj.a143 Hicks GE, Gaines JM, Shardell M, Simonsick EM (2008) Associations of back and leg pain with health status and functional capacity of older adults: findings from the retirement community back pain study. Arthritis Rheum 59:1306-1313. doi: 10.1002/art.24006 Sinikallio S, Aalto T, Airaksinen O, Herno A, Kröger H, Viinamäki H (2009) Depressive burden in the preoperative and early recovery phase predicts poorer surgery outcome among lumbar spinal stenosis patients: a one-year prospective follow-up study. Spine (Phila Pa 1976) 34:2573-2578. doi: 10.1097/BRS.0b013e3181b317bd Skolasky RL, Riley LH, Maggard AM, Wegener ST (2012) The relationship between pain and depressive symptoms after lumbar spine surgery. Pain 153:2092-2096. doi: 10.1016/j.pain.2012.06.026 Jansson KA, Németh G, Granath F, Jönsson B, Blomqvist P (2005) Health-related quality of life in patients before and after surgery for a herniated lumbar disc. J Bone Joint Surg Br 87:959-964. doi: 10.1302/0301-620X.87B7.16240 Schoenfeld AJ, Bono CM (2015) Does surgical timing influence functional recovery after lumbar discectomy? A systematic review. Clin Orthop Relat Res 473:1963-1970. doi: 10.1007/s11999-014-3505-1 Gurung I, Jones MS, Jugurnauth P, Wafai AM (2023) The importance of "time to surgery" in the management of lumbar disc herniation in patients without progressive neurological deficits. J Spine Surg 9:32-38. doi: 10.21037/jss-22-68 Siccoli A, Staartjes VE, de Wispelaere MP, Schröder ML (2020) Association of time to surgery with leg pain after lumbar discectomy: is delayed surgery detrimental? J Neurosurg Spine 32:160-167. doi: 10.3171/2019.8.SPINE19613 Siccoli A, Wispelaere MP, Schröder ML, Staartjes VE (2020) Timing of Surgery in Tubular Microdiscectomy for Lumbar Disc Herniation and Its Effect on Functional Impairment Outcomes. Neurospine 17:204-212. doi: 10.14245/ns.1938448.224 Bailey CS, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, Rosedale R, Bailey SI, Gurr KR, Siddiqi F, Glennie A, Urquhart JC (2020) Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months. N Engl J Med 382:1093-1102. doi: 10.1056/NEJMoa1912658 Sabnis AB, Diwan AD (2014) The timing of surgery in lumbar disc prolapse: A systematic review. Indian J Orthop 48:127-135. doi: 10.4103/0019-5413.128740 Lurie JD, Tosteson TD, Tosteson AN, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN (2014) Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976) 39:3-16. doi: 10.1097/BRS.0000000000000088 Melloh M, Staub L, Aghayev E, Zweig T, Barz T, Theis JC, Chavanne A, Grob D, Aebi M, Roeder C (2008) The international spine registry SPINE TANGO: status quo and first results. Eur Spine J 17:1201-1209. doi: 10.1007/s00586-008-0665-2 Maslak JP, Jenkins TJ, Weiner JA, Kannan AS, Patoli DM, McCarthy MH, Hsu WK, Patel AA (2020) Burden of Sciatica on US Medicare Recipients. J Am Acad Orthop Surg 28:e433-e439. doi: 10.5435/JAAOS-D-19-00174 Gugliotta M, da Costa BR, Dabis E, Theiler R, Jüni P, Reichenbach S, Landolt H, Hasler P (2016) Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open 6:e012938. doi: 10.1136/bmjopen-2016-012938 Dandurand C, Mashayekhi MS, McIntosh G, Singh S, Paquet J, Chaudhry H, Abraham E, Bailey CS, Weber MH, Johnson MG, Nataraj A, Attabib N, Kelly A, Hall H, Rampersaud YR, Manson N, Phan P, Thomas K, Fisher C, Charest-Morin R, Soroceanu A, LaRue B, Dea N (2023) Cost consequence analysis of waiting for lumbar disc herniation surgery. Sci Rep 13:4519. doi: 10.1038/s41598-023-31029-5 van den Hout WB, Peul WC, Koes BW, Brand R, Kievit J, Thomeer RT, Group L-THSIPS (2008) Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ 336:1351-1354. doi: 10.1136/bmj.39583.709074.BE Glennie RA, Urquhart JC, Koto P, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, Rosedale R, Bailey SI, Gurr KR, Siddiqi F, Bailey CS (2022) Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy. Clin Orthop Relat Res 480:574-584. doi: 10.1097/CORR.0000000000002001 Graver V, Ljunggren AE, Loeb M, Haaland AK, Lie H, Magnaes B (1998) Background variables (medical history, anthropometric and biological factors) in relation to the outcome of lumbar disc surgery. Scand J Rehabil Med 30:221-225. doi: 10.1080/003655098443968 Khan I, Bydon M, Archer KR, Sivaganesan A, Asher AM, Alvi MA, Kerezoudis P, Knightly JJ, Foley KT, Bisson EF, Shaffrey C, Asher AL, Spengler DM, Devin CJ (2019) Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery. Spine J 19:1969-1976. doi: 10.1016/j.spinee.2019.08.007 Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6263561","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436397508,"identity":"38728011-1e19-4462-a3a0-909e186e7377","order_by":0,"name":"Jack Horan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACxgYGZmYwi70BSBiQpIXnAJFagACqRSKBSIcxtx9+bFxQcU/eXPLtw48/Chjk+cUOEHBYT5px8owzxYY7Z6cbS/MYMBjOnE3AOsaGHObDvG0JjBtup7ExA/2SYHCbkJb+N2At9htuHmNj/EGUlhk5zMlALYkbbrCxMfAQp+WZsTHPmYTkDWfSmIF+kSDsF8P+5MfSPBUJthuOH2P8+OOPjTy/NCEtDah8CfzKQUCesJJRMApGwSgY8QAAkyw8HJI2YZ0AAAAASUVORK5CYII=","orcid":"","institution":"Beaumont Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jack","middleName":"","lastName":"Horan","suffix":""},{"id":436397509,"identity":"134c0019-3d7c-4a6b-83d9-f43a35d901f8","order_by":1,"name":"Lena Mary Houlihan","email":"","orcid":"","institution":"Beaumont Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lena","middleName":"Mary","lastName":"Houlihan","suffix":""},{"id":436397510,"identity":"deb9f0ad-7491-4714-bf3d-fdc6be57d307","order_by":2,"name":"Paula Corr","email":"","orcid":"","institution":"Beaumont Hospital","correspondingAuthor":false,"prefix":"","firstName":"Paula","middleName":"","lastName":"Corr","suffix":""},{"id":436397511,"identity":"6e415846-79ab-4ea3-9f08-be6d4225ee96","order_by":3,"name":"Deirdre Nolan","email":"","orcid":"","institution":"Beaumont Hospital","correspondingAuthor":false,"prefix":"","firstName":"Deirdre","middleName":"","lastName":"Nolan","suffix":""},{"id":436397512,"identity":"c03f623c-bd66-4d6f-a05b-4945c8ec3578","order_by":4,"name":"Mohammed Ben Husien","email":"","orcid":"","institution":"Beaumont Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Ben","lastName":"Husien","suffix":""}],"badges":[],"createdAt":"2025-03-19 17:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6263561/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6263561/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80045563,"identity":"e5729ddc-66fa-4ca9-880f-566a489641c1","added_by":"auto","created_at":"2025-04-07 09:44:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":646847,"visible":true,"origin":"","legend":"\u003cp\u003eCore Outcome Measures Index (COMI) assessment\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6263561/v1/4c65e281a4161a64a9f2b5d3.png"},{"id":83392740,"identity":"0ecb5781-4236-4c39-bc01-780a653fc01c","added_by":"auto","created_at":"2025-05-24 18:31:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1116713,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6263561/v1/da4fd234-e00a-4fa8-9dec-37cabc501722.pdf"},{"id":80045558,"identity":"cf6bdad2-119e-43c4-b755-e34c133104f5","added_by":"auto","created_at":"2025-04-07 09:44:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":29357,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6263561/v1/353961759be2e1cafab2b30f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Examination of quality of life and economic benefit with early lumbar microdiscectomy: A Pilot Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eLumbar discectomy is a common surgical treatment for a prolapsed disc leading to radicular leg pain or sciatica [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 75% of patients with leg pain, symptoms will resolve with conservative treatment by 3 months [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In patients who do not improve within that time period, surgical treatment has been shown to be effective. At 1 year follow-up, surgical treatment was superior to conservative treatment in pain outcomes. This benefit became less pronounced, as follow-up approached 10 years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Surgery has a faster resolution of leg pain, return to normal activities and recovery when compared to conservative treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChronic pain back and leg pain from degenerative spine disease can significantly impact patient\u0026rsquo;s quality of life. The pain can prevent participation in normal activities and can lead to social isolation and patients being unable to work [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Low mood and depressive symptoms may be seen pre-operatively before surgery in degenerative spine disease [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Post-operative improvement in pain can have a positive impact on depressive symptoms [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A Swedish study found that in patients undergoing surgery for lumbar disc disease, health related quality of life (QOL) improved post-operatively. However, in patients with symptoms of leg pain for greater than 6 months, the level of improvement in QOL was reduced [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The optimal timing for lumbar microdiscectomy for radicular pain (and not emergent cauda equina syndrome or with neurological deficit) is debatable, with conflicting results in the literature. There remains a debate on if there should be a time-frame within which these surgeries should be performed, and what that time frame is [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A systematic review proposed that surgery should be performed within 6 months as surgery after 6 months was associated with poorer outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of the study was to assess if performing lumbar discectomies for radicular pain without neurological deficit earlier, lead to improved quality of life outcomes. The health economic benefit of completing surgery in a timely manner has not been explored in depth and this is another focus of the study.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003eA single centre retrospective cohort study reviewing patient demographics and outcomes with the internationally validated Core Outcome Measures Index (COMI) assessment [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Retrospective collection of patient surgical wait times and length of stay was gathered.\u003c/p\u003e \u003cp\u003eThe time parameter was split into waitlisted for surgery for less than one year or more than one year. All patients who underwent primary elective lumbar microdiscectomy in [BLINDED] from January 2020 - December 2021 for radiculopathy were included. Patient symptoms included back pain, leg pain or sensory deficits. All patients had a magnetic resonance imaging (MRI) scan confirming a prolapsed disc with nerve root compression. Exclusion criteria included emergency cauda equina syndrome surgery or patients with a footdrop or neurological deficit. A prospective database of patients who met the inclusion criteria was used to garner data on patient waiting times. Telephone interviews were completed detailing various outcome measures of the COMI questionnaire post-operatively. Length of stay and complications were recorded. Ethical approval was granted by the Hospital\u0026rsquo;s Review Board.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Outcomes\u003c/h2\u003e \u003cp\u003eThe main outcome of the study was to compare quality of life outcome differences between patients presenting to surgery less than versus greater than one year. We wanted to address the following questions:\u003c/p\u003e \u003cp\u003e(1) Does the length of the presentation to surgery have an influence on outcome measures?\u003c/p\u003e \u003cp\u003e(2) Does the length of presentation to surgery have an influence on post-operative length of stay?\u003c/p\u003e \u003cp\u003e(3) Does the length of presentation to surgery have an influence on cost, i.e. cost of length of stay?\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Core Outcome Measures Index (COMI)\u003c/h2\u003e \u003cp\u003eThe COMI and the variables measured are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical Analysis\u003c/h2\u003e \u003cp\u003eStata version MP15 was used for statistical analysis.\u003c/p\u003e \u003cp\u003e \u003cem\u003eP\u003c/em\u003e-values associated with the categorical dependent variables are from ordered logistic regressions. \u003cem\u003eP\u003c/em\u003e-values associated with skewed continuous variables are from Mann-Whitney U-tests for differences of medians, and \u003cem\u003ep\u003c/em\u003e-values associated with continuous variables not exhibiting skew are from t-tests. A \u003cem\u003eP-\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e64 patients were eligible for inclusion to the study. 38 respondents to telephone interview were included in the final analysis. 20 patients (52.6%) underwent microdiscectomy within one year of being listed for surgery. 18 patients (47.4%) underwent microdiscectomy more than one year of being listed for surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Pre-operative symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBack pain was the most common symptom in patients waitlisted for more than one year (38.9%). Buttock/leg pain was the most common symptom in patients waiting less than one year for surgery (50%) (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Post-operative sciatica severity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e‘Sciatica severity’ is tested as a difference in medians, a t-test of difference in means shows a statistically significantly greater value in sciatica severity among those presenting to surgery greater than one year (score of 3.9) compared to those presenting to surgery less than one year (score of 1.8). The test for difference in medians should be reported, and this nears statistical significance (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Post-operative work interference\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall in the study 65.8% of patients had no or minimal work interference. 5 and 5.6% of patients in the less than and more than one year group respectively had substantial work interference post-operatively. 10% of patients in the group less than one year had rated work interference ‘extremely’, in comparison to 22.2% of patients who waited for more than one year for surgery (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Post-operative\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003erest of life symptom satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e‘Rest of life symptom satisfaction’ shows statistically significant differences between the surgical presentation time groups, with those presenting within one year more likely to be very satisfied than those presenting for surgery after one year, and those presenting within one year less likely to be very dissatisfied than those presenting for surgery after one year (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Work Restriction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe number of patients that had no work restrictions post operatively between surgical wait groups of less than or more than one year was very similar (40% versus 38.9%). The number of patients with greater than 21 work days restriction was slightly higher in the greater than one year group at 27.8% compared to 20% in the less than one year group (Table 2) however this did not reach statistical significance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Occupation Restriction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe number of patients with no occupation restriction and greater than 21 days restriction was the same between less than one year and more than one year (55% versus 55.6%; 25% versus 27.8%) (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.7 Satisfaction with care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall 73.7% of patients were very satisfied with their care. 70% and 77.8% were very satisfied in less than one year versus more than one year wait. 10% of patients in the less than one year group were somewhat or very dissatisfied with no patients in the greater than one year group dissatisfied with care (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.8 Help of operative intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall 92.1% of patients felt the operation helped a little to helped greatly. Only 2.6% of respondents felt that the operation made things worse (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.9 Hospital length of stay (days)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHospital length of stay nears a statistically significant difference for those presenting for surgery within one year (median 3 days) compared to those presenting for surgery after one year (median 2 days) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.10 Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall complication rate was 5.6%. 10% (2 patients) experienced a cerebrospinal fluid leak in the surgery less than one year group. No other complications were seen (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.11 Redo surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the n=5 patients who required a re-do surgery, their average LOS is 5 days, for an average cost of €7,500.00. This is statistically significantly greater (mean LOS=5 days, p=.007) than patients who did not have a re-do surgery (mean LOS=2.4 days) (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.12 Cost analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who present for surgery in less than one year stay in the hospital longer and therefore cost more than patients who present for surgery after one year. These differences in means and medians near statistical significance (\u003cem\u003ep\u003c/em\u003e = 0.053). Median cost overall was €3,000. The surgery less than one year had a median cost of €4,500 versus the group who had surgery longer than one year had a median of €3,000 (Table 5).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study is a single centre retrospective cohort study reviewing quality of life outcomes in patients undergoing elective lumbar discectomy for radiculopathy with no neurological deficits. Two groups were included and compared. The first group of patients had surgery less than one year following listing for surgery and were compared to patients who had surgery over one year following wait listing. Patients operated on within one year had significantly better \u0026lsquo;rest of life symptom satisfaction\u0026rsquo; and post-operative \u0026lsquo;sciatica severity\u0026rsquo; scores than patients who waited longer than one year for surgery.\u003c/p\u003e \u003cp\u003eLumbar disc disease and its clinical sequalae is associated with an increased incidence of comorbid medical conditions and poor health-related quality of life [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Many studies comparing lumbar discectomy versus conservative management are for acute disc prolapse, for symptoms ongoing for up to 3 months. These studies have shown surgery is favourable in reducing short-term pain when compared to conservative treatment. However, at one year follow-up, pain rates were no different between surgical and conservatively managed groups [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The optimal timing for lumbar microdiscectomy for radicular pain (and not emergent cauda equina syndrome or with neurological deficit) with regards to pain and quality of life outcomes is up for debate as results in the literature are conflicting. The optimal time to surgery for elective microdisectomy has a wide range, going from as little as two months post symptoms up to 12 months post symptoms with some studies reporting an upper limit of 6 months [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Siccoli et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] included 372 patients who underwent primary tubular microdiscectomy for radicular pain. Their primary outcome was disability as measured on the Oswestry Disability Index (ODI), with a definition of minimal clinically important difference (MCID) as a 30% decrease or more in ODI from baseline to 12 months post-operatively. They have shown that better functional outcomes were seen when patients underwent surgery between 14\u0026ndash;22 weeks after symptoms began. Lower TTS gave a greater chance of a better functional outcome, and propose surgery should be performed no later than 22 weeks following symptom onset. Siccoli et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] performed another analysis on the same patient group with regards to pain outcome and the timing of surgery. Similar methodology was used, with a 30% reduction in pain scores on a numerical scale being defined as a MCID. Surgery within 24 weeks showed an 80% or higher chance of a positive pain outcome. Beyond 24 weeks, the likelihood of a favourable pain outcome was reduced [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Bailey et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] performed a randomised control trial in 128 patients with sciatica for longer than 4 months. Surgical treatment was superior in leg pain outcomes at 6 months, when compared to conservative management. A systematic review that included 11 studies concluded that symptom presence beyond 6 months was likely to lead to reduced recovery following surgical intervention. Within this analysis, 4 studies compared time periods less than 10 or 12 months of symptoms and greater than 10 or 12 months of symptoms pre-operatively. These studies found that pain and or disability was worse in the groups that had symptoms for greater than 10 or 12 months [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A meta-analysis from 2014 including 21 studies showed that the presence of leg pain for a prolonged period had a higher risk of worse outcomes following lumbar disc surgery. As the studies included were heterogeneous in design, a guideline of surgery from 2\u0026ndash;12 months was proposed. They did note that surgery performed within 6 months was most likely to lead to a favourable outcome [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These results were similar in our study, with both pain and rest of life symptom satisfaction significantly worse in the group that waited longer than one year for surgery.\u003c/p\u003e \u003cp\u003eIn contrast, two studies investigating the timing of surgery in lumbar discectomy did not find any difference in outcomes based on timing of surgery. Gurung et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] included 87 patients in their retrospective analysis comparing timing of lumbar microdiscectomy. They grouped patients into three distinct groups, time to surgery less than 6 months, 6 months to 12 months and greater than 12 months. Outcomes were pain measured on the visual analogue scale (VAS) and disability on ODI. Minimal clinically important difference from baseline to 33% for pain and 30% for disability were considered significant. In all patients an improvement on pain and function was observed. They did not observe a significant difference in outcomes of pain or disability at 6 months post-operatively. In an analysis of 283 patients that compared surgery to conservative treatment, early surgery lead to a faster reduction in pain when compared to conservative treatment. However, at 12 months there was no difference in pain between the two groups [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDandurand et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] compared early (less than 60 days following consent) to late surgery (more than 60 days following consent) for elective lumbar discectomy on a cost-comparison analysis in Canada. 493 patients were included, 272 in the early group and 221 patients in the late group respectively. Early surgery conferred an estimated saving of \u003cspan\u003e$\u003c/span\u003e11,234.89 per patient. This was attributed to lower work absenteeism in this group. In people working at time of consenting, there were significantly lower sick days from work overall in the early compared to the late group. No difference in time to return to work or in the return to work rates were seen between groups. Initially, the early group had higher costs due to more emergency room visits, physiotherapy appointments and imaging. This can be explained by their higher pain scores and disability. Post-operatively, a significantly higher proportion of the early group met the MCID for leg pain at 3 months (84.0% vs 75.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.040). A Dutch study across 9 hospitals found that early surgery (within 12 weeks of symptom onset) for sciatica compared to prolonged conservative treatment for 6 months is cost-effective.\u003c/p\u003e \u003cp\u003eThe early surgical group cost \u0026euro;1819 more than the conservative group. The cost of surgery made up the majority of the difference. Following surgery, initially patients had a period of time that they were unable to work. However, the surgery group had less days off work during the remainder of the year when compared to the conservative group. This study concluded early surgery on a cost and quality adjusted life years (QALY) basis was cost effective [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn patients with chronic sciatica (symptoms 4\u0026ndash;12 months), surgery is cost effective when compared to conservative management. Even in patients that crossed over to the surgical arm of the study, the cost-effectiveness remained. The authors propose reasons that surgery had a favourable cost-utility estimate is that there was low crossover past 6 months and as surgery occurred relatively quickly, there were fewer peri-operative costs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As explained above, multiple trials have shown that earlier surgery leads to faster resolution of symptoms, and the longer symptoms are present, the less likely a favourable outcome will be achieved [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The presence of back pain limiting work is a severe burden for patients and society. Getting patients back to work following surgery is an important metric for surgical outcomes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Khan et al [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] performed a retrospective analysis on a national spine registry in the United States. This study included over 12,000 patients and investigated factors that impacted return to work in patients undergoing elective lumbar spine surgery. An independent risk factor in failure to return to work was the presence of symptoms for more than 3 months.\u003c/p\u003e \u003cp\u003eWhile conflicting reports exist on the significance of timing of surgery, our study reflected the evidence of the prevailing majority of studies. The evidence and benefits for earlier surgery are growing and has been repeated in multiple studies. It does stand to reason that functional outcomes are improved by reduced times to surgery. Patients waiting for surgery are often in pain and may be out of work. With the evidence that surgery allows a faster reduction in pain in the short-term, this may translate into the improved QOL that is seen in patients who have surgery in a shorter time-frame, short-term pain is improved and are back at work [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on our data and published data, it would be reasonable to propose that early surgical intervention in appropriate candidates may provide superior patient outcomes and minimises the associated socioeconomic sequalae for both the patient and healthcare system. This rudimentary analysis is predominantly psychosocial and does not consider factors such as patient comorbidities and deeper level cost such as patient loss of income, medications regimes and adjunct therapies such as physical therapy. We propose a maximum waiting time of 6 months for lumbar discectomy for sciatica. This time limit should be non-negotiable, to give the best chance of a positive outcome for patients.\u003c/p\u003e \u003cp\u003eLimitations of this study include the retrospective nature of the study, the small sample size and the low response to our telephone interview (59%). A prospective study where patients pre-operative symptoms and quality of life outcomes may allow a more robust study and any conclusions that may be drawn from the study. There were also variation in timings between surgery and post-operative interview. A randomised control trial comparing early to delayed surgery would be ideal in answering the question if early surgery has improved pain and functional outcomes. This study may be difficult to enrol patients, with the fact that half of the patients will be listed for surgery but will be told that they won\u0026rsquo;t have it at the earliest for 6 months. Patients enrolling in a surgical trial may want surgery to be performed as soon as possible once they agree and may not enrol if they are part of the delayed group.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eRegardless of cost, it is apparent that patient-related outcomes are superior in candidates operated on within one year. Poorer quality of life outcomes highlight how a successful operative intervention is deemed less effective due to delays outside of the surgeon\u0026rsquo;s control. Our results highlight that these operations should be completed in a timely manner to ensure the patient is receiving the highest standard of care and minimise the likelihood of representation. In line with international practice, we propose a maximum wait time of 6 months for an elective microdiscectomy for radicular pain.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDeclaration of competing interest\u003c/h2\u003e \u003cp\u003eThe authors confirm that they have no competing financial interest or personal relationships that could influenced the findings reported in this paper.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.H, L.M.H and M.B.H - wrote main manuscript textJ.H, L.M.H, P.C, D.N - data collectionL.M.H - data analysisL.M.H and M.B.H - study conceptionAll authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRopper AH, Zafonte RD (2015) Sciatica. N Engl J Med 372:1240-1248. doi: 10.1056/NEJMra1410151\u003c/li\u003e\n \u003cli\u003eVroomen PC, de Krom MC, Knottnerus JA (2002) Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 52:119-123\u003c/li\u003e\n \u003cli\u003eWeber H (1983) Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 8:131-140\u003c/li\u003e\n \u003cli\u003ePeul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW, Group L-THSIPS (2008) Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336:1355-1358. doi: 10.1136/bmj.a143\u003c/li\u003e\n \u003cli\u003eHicks GE, Gaines JM, Shardell M, Simonsick EM (2008) Associations of back and leg pain with health status and functional capacity of older adults: findings from the retirement community back pain study. Arthritis Rheum 59:1306-1313. doi: 10.1002/art.24006\u003c/li\u003e\n \u003cli\u003eSinikallio S, Aalto T, Airaksinen O, Herno A, Kr\u0026ouml;ger H, Viinam\u0026auml;ki H (2009) Depressive burden in the preoperative and early recovery phase predicts poorer surgery outcome among lumbar spinal stenosis patients: a one-year prospective follow-up study. Spine (Phila Pa 1976) 34:2573-2578. doi: 10.1097/BRS.0b013e3181b317bd\u003c/li\u003e\n \u003cli\u003eSkolasky RL, Riley LH, Maggard AM, Wegener ST (2012) The relationship between pain and depressive symptoms after lumbar spine surgery. Pain 153:2092-2096. doi: 10.1016/j.pain.2012.06.026\u003c/li\u003e\n \u003cli\u003eJansson KA, N\u0026eacute;meth G, Granath F, J\u0026ouml;nsson B, Blomqvist P (2005) Health-related quality of life in patients before and after surgery for a herniated lumbar disc. J Bone Joint Surg Br 87:959-964. doi: 10.1302/0301-620X.87B7.16240\u003c/li\u003e\n \u003cli\u003eSchoenfeld AJ, Bono CM (2015) Does surgical timing influence functional recovery after lumbar discectomy? A systematic review. Clin Orthop Relat Res 473:1963-1970. doi: 10.1007/s11999-014-3505-1\u003c/li\u003e\n \u003cli\u003eGurung I, Jones MS, Jugurnauth P, Wafai AM (2023) The importance of \u0026quot;time to surgery\u0026quot; in the management of lumbar disc herniation in patients without progressive neurological deficits. J Spine Surg 9:32-38. doi: 10.21037/jss-22-68\u003c/li\u003e\n \u003cli\u003eSiccoli A, Staartjes VE, de Wispelaere MP, Schr\u0026ouml;der ML (2020) Association of time to surgery with leg pain after lumbar discectomy: is delayed surgery detrimental? J Neurosurg Spine 32:160-167. doi: 10.3171/2019.8.SPINE19613\u003c/li\u003e\n \u003cli\u003eSiccoli A, Wispelaere MP, Schr\u0026ouml;der ML, Staartjes VE (2020) Timing of Surgery in Tubular Microdiscectomy for Lumbar Disc Herniation and Its Effect on Functional Impairment Outcomes. Neurospine 17:204-212. doi: 10.14245/ns.1938448.224\u003c/li\u003e\n \u003cli\u003eBailey CS, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, Rosedale R, Bailey SI, Gurr KR, Siddiqi F, Glennie A, Urquhart JC (2020) Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months. N Engl J Med 382:1093-1102. doi: 10.1056/NEJMoa1912658\u003c/li\u003e\n \u003cli\u003eSabnis AB, Diwan AD (2014) The timing of surgery in lumbar disc prolapse: A systematic review. Indian J Orthop 48:127-135. doi: 10.4103/0019-5413.128740\u003c/li\u003e\n \u003cli\u003eLurie JD, Tosteson TD, Tosteson AN, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN (2014) Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976) 39:3-16. doi: 10.1097/BRS.0000000000000088\u003c/li\u003e\n \u003cli\u003eMelloh M, Staub L, Aghayev E, Zweig T, Barz T, Theis JC, Chavanne A, Grob D, Aebi M, Roeder C (2008) The international spine registry SPINE TANGO: status quo and first results. Eur Spine J 17:1201-1209. doi: 10.1007/s00586-008-0665-2\u003c/li\u003e\n \u003cli\u003eMaslak JP, Jenkins TJ, Weiner JA, Kannan AS, Patoli DM, McCarthy MH, Hsu WK, Patel AA (2020) Burden of Sciatica on US Medicare Recipients. J Am Acad Orthop Surg 28:e433-e439. doi: 10.5435/JAAOS-D-19-00174\u003c/li\u003e\n \u003cli\u003eGugliotta M, da Costa BR, Dabis E, Theiler R, J\u0026uuml;ni P, Reichenbach S, Landolt H, Hasler P (2016) Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open 6:e012938. doi: 10.1136/bmjopen-2016-012938\u003c/li\u003e\n \u003cli\u003eDandurand C, Mashayekhi MS, McIntosh G, Singh S, Paquet J, Chaudhry H, Abraham E, Bailey CS, Weber MH, Johnson MG, Nataraj A, Attabib N, Kelly A, Hall H, Rampersaud YR, Manson N, Phan P, Thomas K, Fisher C, Charest-Morin R, Soroceanu A, LaRue B, Dea N (2023) Cost consequence analysis of waiting for lumbar disc herniation surgery. Sci Rep 13:4519. doi: 10.1038/s41598-023-31029-5\u003c/li\u003e\n \u003cli\u003evan den Hout WB, Peul WC, Koes BW, Brand R, Kievit J, Thomeer RT, Group L-THSIPS (2008) Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ 336:1351-1354. doi: 10.1136/bmj.39583.709074.BE\u003c/li\u003e\n \u003cli\u003eGlennie RA, Urquhart JC, Koto P, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, Rosedale R, Bailey SI, Gurr KR, Siddiqi F, Bailey CS (2022) Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy. Clin Orthop Relat Res 480:574-584. doi: 10.1097/CORR.0000000000002001\u003c/li\u003e\n \u003cli\u003eGraver V, Ljunggren AE, Loeb M, Haaland AK, Lie H, Magnaes B (1998) Background variables (medical history, anthropometric and biological factors) in relation to the outcome of lumbar disc surgery. Scand J Rehabil Med 30:221-225. doi: 10.1080/003655098443968\u003c/li\u003e\n \u003cli\u003eKhan I, Bydon M, Archer KR, Sivaganesan A, Asher AM, Alvi MA, Kerezoudis P, Knightly JJ, Foley KT, Bisson EF, Shaffrey C, Asher AL, Spengler DM, Devin CJ (2019) Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery. Spine J 19:1969-1976. doi: 10.1016/j.spinee.2019.08.007\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6263561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6263561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLumbar microdiscectomy is a surgical intervention which improves radiculopathy with lower back pain and quality of life. The health economic benefit of completing surgery in a timely manner has not been explored in depth. We ask to question is early surgery superior in quality of life when compared to late surgery?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective database of patients who met the inclusion criteria was used to garner data on patient waiting times. Telephone interviews were completed detailing various outcome measures of the core outcome measures index (COMI) questionnaire post-operatively. Surgery was early (less than 12 months) or late (more than 12 months).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-operative ‘Sciatica severity’ shows a statistically significantly greater value in sciatica severity among those presenting to surgery greater than one year (score of 3.9) compared to those presenting to surgery less than one year (score of 1.8). ‘Rest of life symptom satisfaction’ shows statistically significant differences between the surgical wait-time groups, with those operated on within one year more likely to be very satisfied than those after one year. Hospital length of stay nears a statistically significant difference for those operated on within one year(median 3 days) compared to those operated on after one year(median 2 days), but this does not reach statistical significance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegardless of cost, it is apparent that patient-related outcomes are superior in candidates operated on within one year. Poorer quality of life outcomes highlight how a successful operative intervention is deemed less effective due to delays outside of the surgeon’s control. Our results highlight that these operations should be completed in a timely manner to ensure the patient is receiving the highest standard of care and minimise the likelihood of representation.\u003c/p\u003e","manuscriptTitle":"Examination of quality of life and economic benefit with early lumbar microdiscectomy: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 09:44:51","doi":"10.21203/rs.3.rs-6263561/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5847ccfc-352c-44a2-80b5-52284ed6ea04","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-24T18:23:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-07 09:44:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6263561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6263561","identity":"rs-6263561","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}