An assessment of nonoperative management strategies in a herniated lumbar disc population: successes versus failures

Key points

1. 0197.0% of 277,941 patients were successfully managed nonoperatively over a 2-year period
2. 02Only 3.0% failed conservative treatment and underwent microdiscectomy
3. 03Male sex (OR 1.494) and opioid use (OR 2.723) were independent predictors of surgical failure
4. 04Patients who eventually had surgery billed nearly double the cost ($1,718 vs $906 per patient)
5. 05Lumbar spine imaging and epidural steroid injections accounted for the largest cost shares in the surgery group

How it was conducted

Design

Retrospective cohort study using the Humana Ortho (HORTHO) insurance database (2007-2017)

Participants

277,941 adult patients (age 19+) with a primary diagnosis of lumbar intervertebral disc herniation

Groups

Successful nonoperative treatment (n=269,713) vs. failed nonoperative therapy who underwent microdiscectomy (n=8,228)

Surveillance window

2 years post-diagnosis (success cohort) or 2 years pre-surgery (surgery cohort)

Treatments tracked

NSAIDs, opioids, muscle relaxants, lumbar epidural steroid injections (LESI), PT/OT, chiropractor visits, imaging, and ED visits

Primary analysis

Multivariate logistic regression for independent predictors of conservative management failure

What they found

• 97.0% (269,713) of patients were successfully managed nonoperatively; 3.0% (8,228) failed and underwent microdiscectomy
• Male sex failure rate was 3.7% vs 2.4% for females; males had OR 1.494 (95% CI 1.428-1.564) for treatment failure
• Opioid use during conservative therapy had OR 2.723 (95% CI 2.526-2.939) for treatment failure
• Patients aged 70-74 had the highest age-related OR for failure at 2.245 (95% CI 2.021-2.497) compared to reference age 50-54
• Patients with prior LESI use had a 4.5% failure rate vs the 3.0% average population failure rate
• Patients presenting to the ED for disc herniation had a 21.5% failure rate
• Average costs over 2 years: $906 per patient in the successful group vs $1,718 per patient in the surgery group
• In the surgery group, lumbar spine imaging accounted for 44.7% and LESIs for 35.5% of total conservative care costs
• Normalized LESI cost was $1,222.89 per patient in the surgery group vs $1,040.73 in the successful group
• Normalized lumbar spine imaging cost was $777.26 per patient in the surgery group vs $384.77 in the successful group
• Patients from the South (OR 0.880, 95% CI 0.834-0.928) and West (OR 0.886, 95% CI 0.813-0.965) were less likely to fail nonoperative therapy than Midwest patients
• Black race (OR 0.553, 95% CI 0.491-0.621) and Hispanic ethnicity (OR 0.309, 95% CI 0.205-0.445) were associated with lower odds of surgical failure compared to White patients

Limitations

• The database includes only Medicare Advantage and privately insured patients; Medicaid patients are excluded, limiting generalizability
• Severity of baseline symptoms was not captured, so the surgery cohort may have had more severe initial presentations, biasing the failure predictors
• Over-the-counter medications and uninsured therapies were not recorded, meaning utilization is likely underestimated
• Patients with comorbidities like obesity and diabetes appeared less likely to fail nonoperative therapy, which likely reflects surgical candidacy bias rather than true treatment effectiveness

Why it matters

For patients

Most people with a herniated lumbar disc can expect to improve without surgery, but men and those taking prescription opioids for back pain have a meaningfully higher chance of eventually needing an operation.

For clinicians

Male sex and opioid use during conservative therapy are the strongest modifiable and demographic predictors of microdiscectomy; early identification of these patients may allow more targeted escalation and avoid prolonged costly nonoperative courses.

For readers

This large real-world study quantifies the success rate of conservative care and highlights cost inefficiencies in patients who ultimately proceed to surgery, supporting earlier surgical decision-making in high-risk subgroups.