What Neurosurgeons Need to Know

“The results of the three parts of the Spine Patient Outcomes Research Trial (SPORT) were published within the 18 months.” In November 2006, the reports of the randomized, controlled trial (RCT) and observational cohort study of herniated lumbar disc (HLD) were published in the Journal of the American Medical Association.8,9 In May 2007, the New England Journal of Medicine published the results of the RCT of the surgical versus nonoperative treatment of degenerative spondylolisthesis.7 Finally, in February 2008, the results of the lumbar spinal stenosis study were published, also in the New England Journal of Medicine. Practicing neurosurgeons are likely to be asked about the results of these studies because they were covered extensively in the popular press, particularly the HLD RCT. Neurosurgeons should be able to discuss with their colleagues and patients the strengths and weaknesses of these studies to help them understand what information the studies provided and, perhaps more importantly, what information they did not. Organized neurosurgery objected to the fundamental hypothesis and design of the SPORT trial in 2003.3 The concern among the neurosurgical leadership arose from the overly simplistic and irrelevant formulation of the study question. By its design, the SPORT HLD RCT would provide data to either reject or not reject the following null hypothesis: “there is no difference in outcome between patients with painful HLD who, after at least 6 weeks, receive continued nonoperative care and those who undergo lumbar microdiscectomy.” The implication of this statement, that nonoperative care and lumbar microdiscectomy are exchangeable interventions and that there exists one superior and one inferior treatment for a disorder as individual and subjective as painful HLD, represents a fundamental misunderstanding of the diagnosis and the patients. The study proceeded without the participation of neurosurgeons.