How to explain this absence of response? More than probably, the relatively limited number of patients included in the study, as in fact had been the case for other series recently published, did not make it possible to supply indications on the recovery prognosis factors. In addition, “when the patients are operated upon very quickly, it is evidently difficult to show the influence of the operation time factor”, states Dr. Annie Dubuisson. Already, a study published in 2009 had shown that an early surgical decision for a LDH deficit (in this series, 56 patients had been operated on within 14 days of the appearance of the deficit) could explain the difficulties involved in showing the prognostic influence of the deficit duration on motor recovery.

The responses of a non-response

While the Belgian study was unable to demonstrate the influence of the deadline, “it showed that the rapidity of surgical intervention is not sufficient to guarantee a recovery in all the patients”, states Prof. Didier Martin. “It therefore gives us an important piece of information with regard to this point. This means that currently, we cannot guarantee the patients that they have a better chance of recovery thanks to an urgent operation”.

The authors from Liege also carried out a synthesis of 5 other studies and compared the results to their own. Two of them had concentrated on severe deficits, like the Liege study. “The conclusions of the 6 series are sometimes divergent concerning the prognostic factors”, explains the team from Liege. However, two of them, including the only prospective study (it concerned 116 patients 33 of whom had severe deficits), conclude that the degree of recovery of a paralyzing LDH is inversely proportional to the severity and duration of the deficit.

From now on, by focussing on their own study and the literature, the neurosurgeons are going to continue their current line of procedure: operating as quickly as possible to decompress the nerve root, including on those occasions when they are not certain that this speed of intervention effectively changes the stakes with regard to recovery. “Because the operation indication is formal, the rapidity remains probably an important factor without necessarily being a barometer for recovery. In any event, it seems logical to us to operate sooner, even though we have not mastered all the parameters”, state Prof. Didier Martin and Dr. Annie Dubuisson.

An act of faith

On one hand, it is necessary to inform patients about the fact that it is still impossible to guarantee that important severe compressions will not recur. “The deeper and more prolonged the paralysis, the more the prognosis is unfavorable. Once the part of the disc that was responsible for the problem has been removed, the nerve that was strongly compressed will have to repair itself. Research work on the reparation of peripheral nerves, including those carried out in Liege, will one day make it possible, we hope, to increase this capacity for self-repair”, States Prof. Martin. He continues, “on the other hand, the interest of this study also consists in reminding all surgeons that they must continue to be convinced that surgery is an act of faith: "We must believe in it, and do everything to make it work. It is because we are convinced that, for example, following serious accidents even if there is only the tiniest hope of preventing paralysis, it is worth getting up in the middle of the night to operate! A paralyzing LDH does not leave the slightest of chances to the patients. Intervening rapidly and trying to stack all the odds in favor of the patient remains important. On the other hand, if we have to wait before intervening, for example, because the patient must cease to take a blood-thinning drug in order to be operated on, this is probably not a major problem”.

Not at the party...

But what happened to the female patient who was given an open opportunity to set the date of her intervention? She had decided to undergo her operation on the Saturday, deciding to miss out on her daughter’s party. Unfortunately this patient only partially recovered. With the benefit of hindsight it is probably safe to assume that a Monday operation would not have changed anything for this patient…

“The rapidity of the decision to operate must continue to be taken in accordance with the interest of the patients, their situation, their age, their professional or sporting demands. As for us, we continue to think that the more we operate early, the more favorable this is. This observation is not evidence- based. But then, it probably never will be…” concludes Dr. Annie Dubuisson.