Long term effects of lumbar disc herniation surgery in adolescents

Background: In Sweden, about 2,900 surgeries due to a lumbar disc herniation are performed yearly, and the surgical incidence is low compared to the incidence in Denmark and Norway. Surgery for lumbar disc herniation in adolescence is rare and few reports on the outcome of surgery exist.

Aims: To investigate if preoperative patient characteristics and the one-year patient-reported outcomes differ between three Nordic countries with different incidence of surgery for lumbar disc herniation. To describe the short and long-term outcomes in adolescents and adults treated surgically for lumbar disc herniation. Study population: Individuals treated surgically for lumbar disc herniation and registered in the nationwide spine registers in Sweden, Denmark and Norway. Age and sex-matched controls for adolescents treated surgically due to a lumbar disc herniation.

Methods: Data on surgery and patient-reported outcome were acquired from the spine registers. Magnetic resonance imaging (MRI) was performed in a subgroup of the adolescent patients and in all controls.

Results: When comparing Sweden, Denmark and Norway, we found no clear association between incidence of surgery for lumbar disc herniation, patient characteristics and outcome, despite of an up to two-fold variation in surgical incidence. Adolescents (≤18 years old) account for only 1.4% of the lumbar disc herniation surgeries in Sweden. At short-term follow-up, adolescents are more satisfied with their treatment compared to adults (≥19 years old). All groups benefitted significantly from their surgery but the mean values for quality of life were still lower than the average of the general population. At long-term follow-up, adolescents have a similar risk to young adults (19-39 years old) of having to undergo additional lumbar spine surgery, with about 16% of the adolescents and 18% of the young adults needing repeat surgery. When comparing elderly patients (60 years and older) to adults aged 40-59 years old, the elderly had a slightly smaller risk of additional lumbar spine surgery, with repeat surgery occurring in about 11% of the elderly and 14% of the adults. Within all age groups, there were no clinically relevant changes between short and long-term follow-up. More than a decade after surgery, individuals operated on due to a lumbar disc herniation in adolescence have more degenerative signs, as seen on MRI, at the two lower lumbar levels compared to controls. The operated individuals are satisfied to a high degree, but they experience more back disability, more back pain and a lower quality of life compared to controls.

Conclusions: Differences in surgical incidence of lumbar disc herniation is not reflected in differences in preoperative patient characteristics and one-year patient-reported outcome. Surgery for lumbar disc herniation is associated with a 11-18% risk of additional lumbar spine surgery, with a similar risk among adolescents and young adults. There are no clinically relevant changes in outcome between short and long-term follow-up within all age groups, putting into question the need for a long-term follow-up after surgery for lumbar disc herniation. Even though the rate of satisfaction is high, and surgery seems to be a viable alternative, operated adolescents have a higher prevalence of spinal degeneration in the two lower lumbar spine segments and experience slightly more back disability, more back pain and a lower quality of life than age and sex-matched controls more than a decade after their operation.

List of scientific papers

I. An observational study on the outcome after surgery for lumbar disc herniation in adolescents compared with adults based on the Swedish Spine Register. Tobias Lagerbäck, Peter Elkan, Hans Möller, Anna Grauers, Elias Diarbakerli, Paul Gerdhem. The Spine Journal. 2015 Jun 1;15(6):1241-7.
https://doi.org/10.1016/j.spinee.2015.02.024

II. Effectiveness of surgery for sciatica with disc herniation is not substantially affected by differences in surgical incidences among three countries: results from the Danish, Swedish and Norwegian spine registries. Tobias Lagerbäck, Peter Fritzell, Olle Hägg, Dennis Nordvall, Greger Lønne, Tore K. Solberg, Mikkel Ø. Andersen, Søren Eiskjær, Martin Gehrchen, Wilco C. Jacobs, Miranda L. van Hooff, Paul Gerdhem. European Spine Journal. 2019 Nov;28(11):2562-2571.
https://doi.org/10.1007/s00586-018-5768-9

III. Lumbar disc herniation surgery in adolescents and young adults: a long-term outcome comparison. Tobias Lagerbäck, Hans Möller, Paul Gerdhem. The Bone and Joint Journal. 2019 Dec;101-B(12):1534-1541.
https://doi.org/10.1302/0301-620X.101B12.BJJ-2019-0621.R1

IV. Outcome after lumbar disc herniation surgery in adults and elderly – Risk of additional surgery and PROM change over time. Tobias Lagerbäck, Hans Möller, Paul Gerdhem. [Manuscript]

V. MRI characteristics mean 13 years after lumbar disc herniation surgery in adolescence - a case control study. Tobias Lagerbäck, Granit Kastrati, Hans Möller, Karin Jensen, Mikael Skorpil, Paul Gerdhem. [Manuscript]