Lumbar decompression for sciatica is a very common procedure, being performed over 480,000 times per year in the United States. Traditionally, decompression was performed as an “open” approach.
During “open” decompression, often a multi-inch incision is made, the large back muscles are elevated off the spine, bone is removed, and the nerves are decompressed. However with the refinement of surgical instruments, “minimally invasive” techniques were introduced to reduce invasiveness and improve outcomes such as leg pain, back pain, recovery time, and risk of future surgery.
Extensive research has been conducted, largely showing “minimally invasive” approaches offering:
- Smaller surgical scar
- Less disruption of tissue
- Lower infection rate
- Less disruption of tissues.
- Less postoperative instability
Minimally invasive spine surgery now also facilitates awake procedures.
Unfortunately, there is a fairly step learning curve to tubular “minimally invasive” techniques, so about 80% of spine surgeons still only offer “open” surgery. Only about 14% offer tubular “minimally invasive” approaches.
When a patient seeks surgery for sciatica, unless they specifically search out a technique, they commonly proceed with whatever technique their surgeon offers. But what if patients had a choice? What would factor into the patient’s decision?
A study out of the Netherlands sent questionnaires to patients about their preferences, including:
- Waiting time for surgery
- Out-of-pocket costs
- Size of surgical scar
- Use of general anesthesia (asleep surgery)
- Need for hospitalization
- Effect on leg pain
- Duration of the recovery period
Of interest, the size of surgical scar essentially did not factor at all into patient choice of “open” versus “minimally invasive” surgery. In general, effect on leg pain was ranked to be of the highest importance. Out-of-pocket cost was the second most important. Of note, patients would pay more to receive a treatment with a 10% higher chance of improving leg pain.
Turns out of that improvement in leg pain should be no different between “open” and “minimally invasive” surgery. Both decompress the nerves. Out-of-pocket costs, in the United States, would almost always relate to type of insurance and have little relationship to “open” versus “minimally invasive” surgery. Therefore the issues factoring into patients’ choice for surgical technique, really are not impacted by different surgical techniques…
In the end, at least in the Netherlands, having a small surgical scar, or less-invasive approach, is a non-factor for most patients. It would be interesting to repeat this in the United States. It would be interesting if other factors had been included in the questionnaire, such as risks of future fusion or reduction in complications, and whether or not this would affect patient decisions. Other studies have previously suggested that during the surgical consent process, patients often ignore the risk of complications in deciding to pursue surgery.
Gadjradj P et al. Patient preferences for treatment of lumbar disc herniation: a discrete choice experiment. Journal of Neurosurgery Spine. 2021