Lumbar discectomy with lumbar disc implant and its association with quality of life in patients with lumbar disc herniation at a Peruvian military hospital, 2023–2024

Introduction

Low back pain (LBP) is common and is recognized as a major global health problem. The World Health Organization estimates that musculoskeletal conditions affect approximately 1.71 billion people, and LBP is one of the most frequently reported complaints, with an estimated prevalence of 568 million individuals worldwide.^1,2 LBP is also a leading cause of disability across many countries, and despite its high burden, only a minority of patients receive a definitive clinical diagnosis in routine practice.^3,4

Lumbar disc herniation (LDH) is one of the most common causes of LBP associated with sciatica and typically occurs at the L4–L5 and L5–S1 levels.^5-7 LDH is often linked to degenerative processes and mechanical–postural factors that contribute to gradual disc wear, including sustained overload, poor posture, excess body weight, and muscular imbalance—particularly weakness of lumbar stabilizing muscles.⁴ Disc material displacement through the annulus fibrosus, commonly in the posterolateral region, may irritate or compress lumbar nerve roots and the dural sac, resulting in pain, functional limitation, and reduced quality of life.^8,9

Management of LDH includes conservative treatment, interventional procedures, and surgery. Conservative treatment is effective in many patients within four to six weeks and commonly combines medication with supervised rehabilitation strategies; controlled strengthening programs may improve symptoms and function in the short to medium term.^10,11 Surgical treatment aims to decompress neural structures and is generally considered in patients with persistent, disabling radicular pain after an adequate trial of conservative management, in the presence of relevant motor deficits, or urgently in severe presentations such as cauda equina syndrome.^7,10 In selected refractory cases, therapeutic injections may be used to control radicular and axial pain, including selective foraminal blocks, translaminar epidural injections, and facet blocks; serious complications are reported infrequently.^12,13

Because LDH affects pain, daily function, and work capacity, outcomes should be assessed using patient-reported measures in addition to clinical evaluation. Health-related quality of life (HRQoL) reflects physical functioning, pain, emotional well-being, and social participation, and its measurement helps evaluate treatment effectiveness and supports cost–benefit discussions in clinical care.^6,14,15 Prior studies have described HRQoL changes after different surgical and non-surgical approaches, although results vary depending on technique, rehabilitation, patient characteristics, and follow-up duration.^16,17 In Peru, national evidence on HRQoL and disability in LDH remains limited, and available studies have focused mainly on rehabilitation strategies and clinical patterns rather than direct comparisons of HRQoL by surgical approach.^18,19

In particular, there is scarce contemporary local evidence assessing HRQoL in patients treated with lumbar discectomy combined with lumbar disc implantation, especially in physically demanding populations such as military personnel. This gap limits local benchmarking and patient counseling and makes it difficult to contextualize outcomes in defense-sector hospitals.

Therefore, this study aimed to assess the association between discectomy plus lumbar disc implantation and HRQoL in adults with LDH treated at Hospital Central de la Fuerza Aérea del Perú (Hospital Central FAP), Lima, during 2023–2024, using the SF-36 questionnaire to compare patient-reported outcomes between surgically treated and non-surgically treated patients.^1,20

Methods

Results

A total of 95 patients who underwent lumbar discectomy for lumbar disc herniation at a public hospital in Lima, Peru, between 2023 and 2024 were included in the analysis. Of these, 56 patients received a lumbar disc implant, while 39 underwent discectomy without implant placement. Regarding sex distribution, males predominated in both groups, accounting for 55.4% of patients in the implant group and 53.8% in the non-implant group, while females represented 44.6% and 46.2%, respectively in Table 1. No statistically significant differences were observed in sex distribution between the two groups (p = 0.879). The mean age of patients with a lumbar disc implant was 45.7 ± 14.1 years, compared to 45.6 ± 14.3 years in those without an implant. Similarly, median age values were comparable between groups, with medians of 46 years (interquartile range [IQR]: 34–56) in the implant group and 44 years (IQR: 33–57) in the non-implant group in Table 1. No statistically significant differences were identified in age between the groups (p = 0.963), indicating a homogeneous distribution of baseline demographic characteristics in Table 1.

Patients who underwent lumbar discectomy with lumbar disc implant (n = 56) showed consistently higher mean scores across all SF-36 domains compared with those treated without implant (n = 39). In the physical health–related domains, physical function scores were higher in the implant group (33.4 ± 17.1) than in the non-implant group (28.2 ± 16.1), with a mean difference of 5.2 points (95% CI: −1.2 to 11.6), although this difference did not reach statistical significance (p = 0.112). Similarly, role limitations due to physical health were greater among patients with implant (50.2 ± 27.2) compared to those without implant (42.1 ± 25.3), yielding a mean difference of 8.1 points (95% CI: −2.0 to 18.2; p = 0.116). Bodily pain scores were also higher in the implant group (28.8 ± 11.4 vs. 25.7 ± 9.7), with a mean difference of 3.1 points (95% CI: −1.1 to 7.3; p = 0.150). General health perception followed the same trend, with higher mean scores in patients with implant (26.2 ± 7.8) compared to those without implant (23.6 ± 5.8), approaching statistical significance (mean difference: 2.6; 95% CI: −0.1 to 5.3; p = 0.062) in Table 2.

In contrast, statistically significant differences were observed in several mental and social health domains. Vitality scores were significantly higher in the implant group (63.9 ± 18.8) than in the non-implant group (55.0 ± 17.7), with a mean difference of 8.9 points (95% CI: 1.7 to 16.1; p = 0.016). Role limitations due to emotional problems were notably greater among patients with implant (88.7 ± 17.3) compared to those without implant (77.2 ± 21.7), demonstrating a significant mean difference of 11.5 points (95% CI: 3.7 to 19.3; p = 0.005) in Table 2. Likewise, mental health scores were significantly higher in the implant group (78.6 ± 11.5) than in the non-implant group (71.9 ± 12.4), with a mean difference of 6.7 points (95% CI: 1.9 to 11.5; p = 0.007). Although social functioning scores were also higher in patients who received a lumbar disc implant (62.6 ± 22.5) compared to those without implant (54.6 ± 22.6), the observed mean difference of 8.0 points (95% CI: −0.9 to 16.9) did not reach statistical significance (p = 0.079) in Table 2.

Among the patients included in the study, lumbar disc herniation types were similarly distributed between those who underwent lumbar discectomy with disc implant (n = 56) and those treated without implant (n = 39). In the implant group, disc extrusion was the most frequent presentation, observed in 41.1% of cases, followed by sequestered herniation in 21.4%, migrated herniation in 19.6%, and disc protrusion in 17.9% in Table 3. A comparable pattern was identified in the non-implant group, where extrusion accounted for 43.6% of cases, followed by migrated herniation in 20.5%, protrusion in 20.5%, and sequestered herniation in 15.4%. No statistically significant differences were found in the distribution of herniation types between both groups (p = 0.931), indicating that baseline morphological characteristics of lumbar disc herniation were homogeneous regardless of implant use in Table 3.

Among patients who underwent lumbar discectomy with lumbar disc implant, the presence of comorbidities was observed in 30 individuals (53.6%), while 26 patients (46.4%) reported no associated comorbid conditions. The overall quality of life, assessed using the SF-36 total score, was slightly lower in patients with comorbidities compared to those without comorbidities (52.7 ± 12.9 vs. 56.4 ± 13.6, respectively) in Table 4. However, this difference did not reach statistical significance (p = 0.323), indicating that the presence of comorbidities was not significantly associated with variations in overall quality of life among patients treated with lumbar disc implantation during the study period in Table 4.

In the multivariable analysis assessing factors associated with quality of life among patients with lumbar disc herniation treated at a public hospital in Lima, Peru, during 2023–2024, lumbar discectomy with lumbar disc implant was significantly associated with better quality-of-life outcomes. Patients who underwent discectomy with implant showed a higher prevalence of improved quality of life compared with those without implant placement, both in the crude analysis (PR: 1.66; 95% CI: 1.00–2.76; p = 0.05) and after adjustment for potential confounders (adjusted PR: 1.68; 95% CI: 1.02–2.79; p = 0.043) in Table 5. In contrast, age was not significantly associated with quality of life, either in the crude model (PR per year: 1.01; 95% CI: 0.99–1.03; p = 0.408) or in the adjusted analysis (adjusted PR: 1.01; 95% CI: 0.99–1.03; p = 0.373), indicating no meaningful effect of increasing age on the outcome. Similarly, sex did not show a significant association with quality of life, as female patients had a prevalence ratio comparable to male patients in both the crude (PR: 0.92; 95% CI: 0.61–1.39; p = 0.684) and adjusted models (adjusted PR: 0.91; 95% CI: 0.61–1.37; p = 0.651) in Table 5.

Discussion

Our findings suggest that lumbar discectomy combined with disc implantation is associated with better health-related quality of life compared with discectomy alone in Peruvian adults with lumbar disc herniation. Patients who received an implant showed a 68% higher prevalence of improved quality of life after adjustment for age and sex (adjusted PR: 1.68; 95% CI: 1.02–2.79; p = 0.043). The largest differences were observed in vitality, emotional role, and mental health domains, whereas physical domains showed modest and non-significant improvements. This pattern is consistent with the findings of Häkkinen et al.,²³ who reported that quality-of-life improvements after lumbar disc surgery extend beyond physical recovery to include emotional and social dimensions. Similarly, the systematic review by Ostelo et al.²⁴ emphasized the multidimensional nature of postoperative recovery and the importance of rehabilitation in functional outcomes.

A plausible explanation is that effective neural decompression rapidly relieves radicular pain, restoring patients’ confidence in movement and daily activities. In the longitudinal study by Atlas et al.,²⁵ symptomatic relief after surgery was associated with sustained improvements in perceived well-being. Likewise, the randomized trial by Peul et al.²⁶ demonstrated that surgery provides faster pain relief compared with prolonged conservative treatment, which may explain why vitality and emotional role scores were significantly higher in the implant group in our cohort, despite non-significant differences in physical domains.

Our results are also consistent with the long-term follow-up of the Maine Lumbar Spine Study led by Atlas et al.,²⁷ which demonstrated substantial quality-of-life improvements after discectomy, particularly among working-age adults. Additionally, the SPORT trial conducted by Weinstein et al.²⁸ showed that surgical benefits in lumbar disc herniation are primarily driven by symptom relief and functional improvement rather than demographic factors such as age. In our study, age was not significantly associated with quality of life, aligning with these findings.²⁸

Regarding disc implantation, evidence remains more heterogeneous. Zigler and Delamarter²⁹ have suggested that lumbar disc arthroplasty may preserve segmental motion and improve patient satisfaction. Furthermore, the meta-analysis by Park et al.³⁰ reported favorable clinical and radiological outcomes following lumbar total disc replacement. Although bodily pain did not differ significantly between groups in our study, the higher psychosocial domain scores may reflect perceived biomechanical stability and functional confidence as described by these authors.^29,30

Strengths of this study include the use of the validated SF-36 questionnaire developed by Ware and Sherbourne,³¹ which provides comprehensive assessment of health-related quality of life. Baseline homogeneity between groups and the use of prevalence ratios with robust variance strengthen internal validity.

However, the cross-sectional design limits causal inference. The absence of randomization may introduce confounding by indication, as also discussed in the comparative studies by Peul et al.²⁶ and Weinstein et al.²⁸ Future prospective studies are needed to determine whether these differences persist over time and represent clinically meaningful long-term benefits.^27,29

Conclusion

Lumbar discectomy with disc implantation was associated with a higher prevalence of improved health-related quality of life, particularly in vitality, emotional role, and mental health domains. However, due to the cross-sectional design, non-random treatment allocation, and potential residual confounding, these findings should be interpreted cautiously and do not establish causality.