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Orthopaedic Surgery Spine
Lumbar Disc Herniation Surgery and Gender-related Differences
a report by
Björn Strömqvist,
1
M Ahmad,
2
F Strömqvist,
2
C Hildingsson
2
and B Jönsson
1
1. Department of Orthopaedics, Lund University Hospital; 2. Department of Orthopaedics, Norrland’s University Hospital Umeå
Herniation of a lumbar disc has been a diagnosable and treatable entity operative disability was more pronounced for females and their quality of
since the 1930s. Between 2 and 4% of the population of the developed life was inferior in three areas: vitality, general health and mental health
world will be operated on for a lumbar disc herniation during their lifetime. (see Figure 1). Thus, the patients operated on for lumbar disc herniation
It most often manifests as radiating leg pain, often accompanied by lower-
back pain. Diagnosis is reliably established by magnetic resonance imaging
(MRI), although it should be noted that asymptomatic hernations are not
In a prospective and consecutive
infrequent. The main symptom, sciatica, is elicited by a combination of
study with a minimum of 15 years
mechanical and chemical (inflammatory) factors. In fewer than 5% of cases
of follow-up, it was demonstrated
the indication for surgery is absolute because of compression of the nerves
that exert control over the bowel and bladder, or because of progressive that the gender-related differences
paresis of one or both legs. For the remaining 95% of patients the
described short term are retained
indications for surgery are intractable long-standing pain and disability. Pain
and disability are not numerically measurable, and therefore indications
in the long term.
may differ between countries, surgeons and patients. In most large studies
on lumbar disc herniation surgery, males represent about 55% of patients, had high levels of pain and disability. In conclusion, there were
although no difference in incidence between the genders is to be pronounced pre-operative differences between the genders that were
anticipated. Recent epidemiological surveys have indicated that females statistically significant in the above-mentioned parameters.
react differently from males to long-standing musculoskeletal pain, and
also that the experienced pain of a defined nociceptive provocation is Outcome Parameters at One to Two Years
different between the genders. Therefore, we found it greatly interesting
to study whether any such differences could be discerned in a large number Basic Parameters
of patients operated on for lumbar disc herniation. Significant improvement for both genders regarding parameters reflecting
pain (back pain, leg pain, walking ability and consumption of analgaesics)
The Swedish National Spine Register was seen post-operatively. At one year after surgery, working capacity and
The Swedish National Register for Spine Surgery
1
has existed for 15 walking ability were similar between the genders, whereas females
years and has been in general use for the last 10, covering more than consumed analgaesics to a higher extent and reported more residual and
80% of lumbar spine operations in Sweden. It studies patient-reported pronounced back pain (see Figure 2). Leg pain, which is the main
data on demographics and outcomes, and provides a good basis for indication for surgery, decreased to a significant extent for both groups,
examining whether gender differences in patient selection and outcome but more so for males (see Figure 3). The same was found for disability.
of surgery exist. In addition to reporting pain relief, the register also While three-quarters of the males experienced no disability after surgery,
contains other pre- and post-operative data supporting the surgical this was true for only half of the females. Quality of life improved to a high
result, such as pain on the visual analogue scale (VAS) graded from zero extent for both genders, but physical function, bodily pain and vitality
to 100, quality of life and disability related to the spinal disorder. were better in the male group (see Figure 4). Concerning pain, the relative
improvement did not differ. Mean reduction in leg pain (VAS) was 36 for
Pre-operative Demographics females and 40 for males, and mean reduction in back pain was 20 and
In a six-year cohort from one institution,
2
301 consecutive patients (161 16, respectively. The overall satisfaction with surgery was similar between
males and 136 females) were operated on and their data analysed. Mean
age for both genders was 42 years (range 18–82). Most patients in both
Björn Strömqvist is a Professor of Orthopedics at Lund
groups had experienced leg and back pain for three to 12 months before
University Hospital. His research interests include spinal
surgery. Smokers were over-represented, especially among the females: stability, outcome studies, tumours, fractures and minimally
36% of the females were smokers compared with 14% of the national
invasive lumbar spine surgery. Professor Strömqvist is a
member of the Swedish Society for Spine Surgeons, the
population, and corresponding figures for males were 27 and 19%,
North American Spine Society (NASS) and the International
respectively. While pre-operative leg pain was graded similarly by both
Society for Study of the Lumbar Spine (ISSLS). He has
published over 200 peer-reviewed articles and is an
genders on the VAS, females graded higher back pain than males (mean
Editorial Board member of Spine, Spine Journal and the
54 versus 43). Consumption of analgaesics was more common among European Spine Journal.
females, but the walking distance before surgery did not differ. Two
E:
bjorn.stromqvist@med.lu.se
questionnaires of the register evaluate disability and quality of life. Pre-
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