Abstract
Introduction
Sexual health is an important aspect of wellbeing and is often impaired in younger adults with lumbar disc herniation (LDH). Evidence describing postoperative sexual health specifically in this age group remains limited.
Research question
How does self-reported sexual health change from before to one year after lumbar discectomy in patients aged 18–50?
Material and methods
This cohort study used prospectively data from the Danish registry DaneSpine. Patients aged 18–50 undergoing single-level lumbar discectomy between 2010 and 2022 were included. The primary outcome was sexual health measured using ODI item 8 (“My sex life is?”). Secondary outcomes were visual analogue scale (VAS) scores for back and leg pain. Changes from baseline to one year were analyzed with Wilcoxon signed-rank tests (ODI item 8) and paired t-tests (VAS).
Results
A total of 1599 patients were included (mean age 38.5 years; 47.4% female). Preoperatively, 54.7% reported a severely restricted, nearly absent, or absent sex life due to pain. Mean VAS scores were 47.5 for back pain and 70.5 for leg pain. At one year, only 11.7% reported severely restricted or worse sexual health (p < 0.001). In contrast, 53.1% reported a normal sex life without extra pain and 25.8% reported a normal sex life with some extra pain. VAS scores improved to 29.3 (back) and 24.9 (leg) (p < 0.001).
Discussion and conclusion
Younger adults with LDH experience improvement in pain-related sexual dysfunction after lumbar discectomy. One year postoperatively, more than 78% report a normal or nearly normal sex life.
Keywords: Disc herniation, Discectomies, DaneSpine, Sexual health, Oswestry disability index
Highlights
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This is a cohort study focusing on younger adults (18–50) undergoing lumbar discectomy and their postoperative sexual health.
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More than half of all patients reported severe pain-related sexual dysfunction before surgery.
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At one year, only 11.7% continued to report severely restricted or absent sex life, representing a major improvement.
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Over 78% of patients reported a normal or nearly normal sex life after lumbar discectomy.
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Results provide counseling material for clinicians treating younger patients with LDH and pain-related sexual dysfunction.
1. Introduction
In the majority of patients, the natural course of lumbar disc herniation (LDH) is favorable. However, in some cases, the pain persists for several weeks to months despite non-operative treatment (Saal, 1996). These patients may benefit from surgical treatment with lumbar discectomy (Rickers et al., 2021). Recent studies have investigated patient-reported sexual health before and after surgical treatment for LDH. However, these studies have either a narrow focus on male patients alone (Panneerselvam et al., 2022), or a broad focus on all surgically treated patients in both larger (Holmberg et al., 2020a), (Nakajima et al., 2021a) and smaller cohorts (Kanayama et al., 2010a), (Elsharkawy et al., 2018), (Häkkinen et al., 2007), (Akbaş et al., 2010a) regardless of age and pathology. There is a lack of studies on the sexual health among younger patients undergoing lumbar discectomies, even though sexual health seems to matter the most for this group (Flynn et al., 2017).
In the current study, we investigated the effect of lumbar discectomy on the self-reported sex life among patients aged 18 to 50. Our hypothesis is that lumbar discectomy improves the sexual health among patients with impaired sexual health before surgery. This may guide spine care providers in counseling younger patients on their expected sexual health following lumbar discectomy.
2. Methods
2.1. Study design and data source
This was a single-center, longitudinal, observational cohort study using data from the Danish Spine Surgery Registry (DaneSpine) (“[Implementation of the Danish national). DaneSpine was implemented at the Spine Centre of Southern Denmark in 2010; since then, ∼99% of eligible patients have been enrolled at the time of surgery, and registry-level 1-year follow-up completeness is ∼84% (“[Implementation of the Danish national). The registry contains patient characteristics, surgical details and patient reported outcome measures (PROMs). PROMs are collected both pre- and postoperatively and include, among others, Oswestry Low Back Disability Index (ODI) (Fairbank et al., 1980), (Fairbank and Pynsent, 2000) and visual analogue scale (VAS) for both back and leg pain.
The national Danish guidelines for lumbar radiculopathy recommend referral for surgical evaluation if symptoms persist despite non-operative treatment for a minimum of 12 weeks (Sundhedsstyrelsen, 2018). Thus, the patients included in this study all were diagnosed with disc herniation, which was unresponsive to non-operative treatment, but without indications for urgent surgical intervention such as neurologic deficit.
2.2. Study cohort
Patients aged 18 to 50 years who underwent surgical treatment for symptomatic lumbar disc herniation with concordant MRI findings at the Spine Centre of Southern Denmark between January 1, 2010, and December 31, 2022, were eligible for inclusion. By protocol, patients with cauda equina syndrome (CES) are operated at the regional university hospital rather than at our spine center; accordingly, no patients with CES were included. Exclusion criteria for the primary cohort included: missing responses to ODI item 8 ("My sex life is?") in the preoperative assessment, a history of previous spine surgery, surgical intervention at more than one spinal level, and absence of reported sexual dysfunction. Non-responders and patients without sexual dysfunction who met all other criteria were assigned to two secondary cohorts for comparison.
2.3. Baseline characteristics
DaneSpine consists of both patient-registered and surgeon-registered data, where the patients report all pre- and postoperative data, and the surgeon reports perioperative data. Sex and age are derived from the patients’ civil registration number (Schmidt et al., 2014). Preoperative patient reported variables included weight, height, smoking status, and prior spine surgery. Surgeon-registered variables included level of herniation, location of herniation (paramedian, central, lateral), surgical procedure (microdiscectomy, open discectomy, or percutaneous discectomy) and complications during surgery.
2.4. Outcome
The patients complete the ODI questionnaire before and one year after discectomy together with VAS for their back and leg pain. The primary outcome in this study was ODI item 8, which is:
Question: My sex life is?
Answers.
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(1)
Normal with no extra pain
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(2)
Normal with some extra pain
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(3)
Nearly normal but very painful
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(4)
Severely restricted by pain
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(5)
Nearly absent because of pain
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(6)
Pain prevents any sex life at all
Secondary outcomes were VAS score for back and leg pain and total ODI score.
2.5. Sample size calculation
Based on the current literature (Holmberg et al., 2020b), we expected that one in every six patients would report that pain prevented any sex life at all (ODI item 8 = 5) (Holmberg et al., 2020b). Following surgery, this number was expected to be less than 5%. To reach a significance level of 0.05 and a power of 80%, at least 135 patients had to be included in the “Pain prevents any sex life at all” category at baseline.
2.6. Statistics
Continuous variables are presented as mean and standard deviation (SD) and categorical variables as frequency and percentages. Responses to ODI item 8 were compared by Wilcoxon signed-rank test and VAS back and leg pain by paired-samples t-test. Responses to ODI item 8 were treated as paired ordinal data, with each of the response categories analyzed individually. Responses to ODI item 8 were coded 0–5 and compared pre-to postoperatively using the Wilcoxon signed-rank test. VAS back and leg pain were compared with paired-samples t tests. A two-sided α of 0.05 defined statistical significance. All analyses were conducted in SPSS (v28).
3. Results
3.1. Study cohort
Of 4645 patients screened, 1978 were >50 years, 399 had prior spine surgery, and 138 underwent multi-level surgery, leaving 2130 eligible for baseline ODI item 8. Of these, 1833 (86.1%) completed ODI item 8 at baseline and 297 (13.9%) did not. Among baseline responders, 1599 (87.3%) reported sexual dysfunction and 234 (12.8%) reported no dysfunction. The 234 patients who reported no sexual dysfunction were excluded from this analysis. At 12 months, ODI item 8 was available for 1020/1599 (63.8%) in the sexual-dysfunction cohort; 579/1599 (36.2%) were lost to follow-up or had missing ODI item 8 at 12 months (Fig. 1).
Fig. 1.
Study cohort: Lumbar discectomies January 1st, 2010 – December 31st, 2022.
3.2. Baseline characteristics
The average age of the cohort was 38.5 years (SD: 7.6) and 787 (47.4%) were females (Table 1). The average BMI was 26.9 (SD: 4.6). At baseline, 552 (34.8%) reported that they were smokers. All patients had a one-level discectomy.
Table 1.
Baseline characteristics for LDH patients presented as Mean (SD) or proportions.
| Characteristic | Sexual dysfunction |
|---|---|
| Number of patients, (n) | 1.599 |
| Age, years, mean (SD) | 38.5 (7.6) |
| Gender, females, n (%) | 758 (47.4) |
| Smoker, n (%) | 552 (34.8) |
| BMI, mean (SD) | 26.9 (4.6) |
| Comorbidity, n (%) | 163 (10.2) |
| Duration of pain in leg, No pain, n (%) | 7 (0.4) |
| Duration of pain in leg, <3 months, n (%) | 435 (27.2) |
| Duration of pain in leg, 3 - 12 months, n (%) | 829 (51.9) |
| Duration of pain in leg, 1 - 2 years, n (%) | 174 (10.9) |
| Duration of pain in leg, >2 years, n (%) | 152 (9.5) |
| Missing, n | 2 |
| Duration of pain in back, No pain, n (%) | 74 (4.7) |
| Duration of pain in back, <3 months, n (%) | 229 (14.4) |
| Duration of pain in back, 3 - 12 months, n (%) | 690 (43.4) |
| Duration of pain in back, 1 - 2 years, n (%) | 205 (12.9) |
| Duration of pain in back, >2 years, n (%) | 393 (24.7) |
| Missing, n | 8 |
| Functional impairment (ODI), mean (SD) | 49.7 (16.8) |
| VAS pain (leg), mean (SD) | 70.2 (22.5) |
| VAS pain (back), mean (SD) | 50.4 (28.6) |
| Quality of life (EQ-5D-3L), mean (SD) | 0.266 (0.327) |
| SF-36, Physical Component Score, mean (SD) | 28.9 (6.6) |
| SF-36, Mental Component Score, mean (SD) | 42.9 (11.3) |
Abbreviations: SD, standard deviation; ODI, Oswestry Disability Index; VAS, visual analogue pain scale; SF-36, 36-Item Short Form Survey. Counts may not sum to the total sample size due to item-level missing data.
3.3. Sexual health
Before lumbar discectomy, 431 (27.0%) reported a normal sex life with some extra pain, 293 (18.3%) reported a nearly normal sex life but very painful, 323 (20.2%) reporting sex life severely restricted by pain, 279 (17.4%) reported nearly absent sex life because of pain and 273 (17.1%) reported that their sex life was absent.
One year after discectomy, there was a significant change in this distribution (p < 0.001) with 542 (53.1%) reporting a normal sex life, 263 (25.8%) reported a normal sex life with some extra pain, 96 (9.4%) reported a nearly normal sex life but very painful, 63 (6.2%) reporting sex life severely restricted by pain, 39 (3.8%) reported nearly absent sex life because of pain and 17 (1.7%) reported that their sex life was absent (Table 2).
Table 2.
Outcome for LDH patients presented as Mean (SD) or proportions.
| Outcome | Baseline | 1-year follow-up | dif. | p-value |
|---|---|---|---|---|
| ODI item 8 - My sex life is: | ||||
| Normal with no extra pain, n (%) | 0 (0.0) | 542 (53.1) | 53.1 | <0.001a |
| Normal with some extra pain, n (%) | 431 (27.0) | 263 (25.8) | 1.2 | |
| Nearly normal but very painful, n (%) | 293 (18.3) | 96 (9.4) | 8.9 | |
| Severely restricted by pain, n (%) | 323 (20.2) | 63 (6.2) | 14.0 | |
| Nearly absent because of pain, n (%) | 279 (17.4) | 39 (3.8) | 13.6 | |
| Pain prevents any sex life at all, n (%) | 273 (17.1) | 17 (1.7) | 15.4 | |
| Functional impairment (ODI), mean (SD) | 49.7 (17.0) | 21.3 (17.7) | 28.4 | <0.001a |
| VAS pain (leg), mean (SD) | 70.5 (21.8) | 24.9 (27.6) | 45.6 | <0.001a |
| VAS pain (back), mean (SD) | 47.5 (28.8) | 29.3 (27.9) | 18.2 | <0.001a |
| Quality of life (EQ-5D-3L), mean (SD) | 0.266 (0.327) | 0.701 (0.295) | 0.435 | <0.001b |
| SF-36, Physical Component Score, mean (SD) | 29.1 (6.7) | 43.1 (11.0) | 14.0 | <0.001a |
| SF-36, Mental Component Score, mean (SD) | 42.9 (11.3) | 74.5 (21.2) | 31.6 | <0.001a |
Abbreviations: SD, standard deviation; ODI, Oswestry Disability Index; VAS, visual analogue pain scale; SF-36, 36-Item Short Form Survey. a Paired-samples T-test.
Wilcoxon Signed-ranks test.
We found that non-responders were younger (2.7 years), had slightly less leg pain, better quality of life (EQ-5D) and better mental health at baseline (Table 3).
Table 3.
Baseline characteristics for LDH patients (ODI item 8 responders vs non-responders) presented as Mean (SD) or proportions.
| Outcome | Females | Males | dif. | p-value |
|---|---|---|---|---|
| ODI item 8 (Baseline) - My sex life is: | ||||
| Normal with no extra pain, n (%) | 0 (0.0) | 0 (0.0) | <0.001c | |
| Normal with some extra pain, n (%) | 179 (23.6) | 252 (30.0) | 6.4 | |
| Nearly normal but very painful, n (%) | 124 (16.4) | 169 (20.1) | 3.7 | |
| Severely restricted by pain, n (%) | 163 (21.5) | 160 (19.0) | 2.5 | |
| Nearly absent because of pain, n (%) | 141 (18.6) | 138 (16.4) | 2.2 | |
| Pain prevents any sex life at all, n (%) | 151 (19.9) | 122 (14.5) | 5.4 | |
| ODI item 8 (Follow-up) - My sex life is: | ||||
| Normal with no extra pain, n (%) | 268 (51.8) | 274 (54.5) | 2.7 | 0.336c |
| Normal with some extra pain, n (%) | 136 (26.3) | 127 (25.2) | 1.1 | |
| Nearly normal but very painful, n (%) | 45 (8.7) | 51 (10.1) | 1.4 | |
| Severely restricted by pain, n (%) | 37 (7.2) | 26 (5.2) | 2.0 | |
| Nearly absent because of pain, n (%) | 24 (3.2) | 15 (3.0) | 0.2 | |
| Pain prevents any sex life at all, n (%) | 7 (1.4) | 10 (2.0) | 0.6 | |
Abbreviations: ODI, Oswestry Disability Index c Wilcoxon Signed-ranks test.
3.4. VAS scores and ODI
There was a statistically significant improvement in PROMs from baseline to 1-year follow-up for the ODI (49.7 to 21.3, p < 0.001), VAS leg pain (70.5 to 24.9, p < 0.001), VAS back pain (47.5 to 29.3, p < 0.001), EQ-5D (0.266 to 0.701, p < 0.001), SF-36-PCS (29.1 to 43.1, p < 0.001) and SF-36-MCS (42.9 to 74.5, p < 0.001).
3.5. Males versus females
A subanalysis comparing males and females showed that females were slightly worse off at baseline, with 60% reporting a severely restricted, nearly absent, or completely absent sex life, compared to 49.9% of men (Table 4). However, this difference was no longer evident at 1-year.
Table 4.
Female and male LDH patients compared presented as proportions.
| Outcome | Females | Males | dif. | p-value |
|---|---|---|---|---|
| ODI item 8 (Baseline) - My sex life is: | ||||
| Normal with no extra pain, n (%) | 0 (0.0) | 0 (0.0) | <0.001c | |
| Normal with some extra pain, n (%) | 179 (23.6) | 252 (30.0) | 6.4 | |
| Nearly normal but very painful, n (%) | 124 (16.4) | 169 (20.1) | 3.7 | |
| Severely restricted by pain, n (%) | 163 (21.5) | 160 (19.0) | 2.5 | |
| Nearly absent because of pain, n (%) | 141 (18.6) | 138 (16.4) | 2.2 | |
| Pain prevents any sex life at all, n (%) | 151 (19.9) | 122 (14.5) | 5.4 | |
| ODI item 8 (Follow-up) - My sex life is: | ||||
| Normal with no extra pain, n (%) | 268 (51.8) | 274 (54.5) | 2.7 | 0.336c |
| Normal with some extra pain, n (%) | 136 (26.3) | 127 (25.2) | 1.1 | |
| Nearly normal but very painful, n (%) | 45 (8.7) | 51 (10.1) | 1.4 | |
| Severely restricted by pain, n (%) | 37 (7.2) | 26 (5.2) | 2.0 | |
| Nearly absent because of pain, n (%) | 24 (3.2) | 15 (3.0) | 0.2 | |
| Pain prevents any sex life at all, n (%) | 7 (1.4) | 10 (2.0) | 0.6 | |
Abbreviations: ODI, Oswestry Disability Index c Wilcoxon Signed-ranks test.
4. Discussion
In this study, we investigated the impact of lumbar discectomy on the sexual health of younger patients. From the national Danish Spine Registry (DaneSpine), we reviewed patient response to Oswestry Disability Index item 8 (ODI item 8), “My sex life is?” before they underwent lumbar discectomy and one year after surgery. Our study showed that 54.7% of patients reported that their sex life was absent, nearly absent or severely restricted due to pain before undergoing surgery. Following surgery, this number was reduced to 11.7%, with 53.1% reporting a normal sex life without extra pain following surgery. The observed shift toward a normal or nearly normal sex life occurred alongside marked improvements in EQ-5D, SF-36 PCS/MCS, and reductions in VAS leg and back pain at one year. Taken together, these concurrent changes indicate that recovery of sexual activity likely tracks with broader health-related quality of life and psychosocial recovery after lumbar discectomy, even though our study was not designed to determine causality or mediation across these domains.
The significant improvement in sexual health aligns with the results from the Norwegian Spine Registry, where Holmberg et al. investigated the sexual health after lumbar discectomy in patients of all ages. The current study cohort was restricted to younger patients and differed from the Norwegian cohort not only in age, but also percentage of females. Two other studies, from Japan and Turkey, reported preoperative restrictions and postoperative improvement of sexual health in patients with LDH (Kanayama et al., 2010b), (Akbaş et al., 2010b). Interestingly, both studies reported that females experienced prolonged restriction in their sexual health compared with males. In our cohort, we analyzed the sexual health one year following surgery and were unable to find any significant difference in the self-reported sex life between males and females. However, the results indicate that the women in our cohort were slightly worse off at baseline, with 60% reporting a severely restricted, nearly absent, or completely absent sex life, compared to 49.9% of men. Culture and tradition might affect how patients think and reply to sensitive questions. The study cohort was treated within the Danish publicly funded healthcare system with structured perioperative pathways and systematic PROM collection. Moreover, cultural norms in Denmark may facilitate open discussion of intimacy in clinical settings. These health service and cultural factors could influence both patient-reported sexual activity and follow-up completeness, and they may differ in health systems with limited rehabilitation access or where sexuality is less openly addressed.
The current study had several important limitations. First, sexual health was captured using a single ODI item (item 8: ‘My sex life is?’), which primarily reflects pain-related activity limitation and does not directly assess desire, arousal, satisfaction, or partner interaction. Future studies should incorporate multidimensional measures such as the International Index of Erectile Function (IIEF) (Rosen et al., 1997)and the Female Sexual Function Index (FSFI) (Rosen et al., 2000) to provide a more comprehensive assessment of sexual function. Second, DaneSpine only collects information on surgically treated patients, making it impossible in this study to compare lumbar discectomy with the natural history of disc herniation or with outcomes after conservative treatment. To our knowledge, no studies have investigated the sexual health of patients with conservatively treated disc herniations, limiting our ability to advise on expected outcomes from non-surgical care. Third, some patients were excluded due to missing responses to ODI item 8. The completeness of ODI item 8 is a well-known challenge when investigating the association between spine surgery and sexual health; in a recent study, Nakajima et al. compared outcomes between responders and non-responders to ODI item 8 and concluded that non-responders seemed to have less severe symptoms (Nakajima et al., 2021b). Fourth, ODI item 8 does not tailor language to gender identity, sexual orientation, relationship status, or psychosocial context, and it presumes ongoing sexual activity. Such nuances may influence both interpretation and willingness to respond, potentially contributing to differential non-response we observed for ODI item 8. Fifth, non-responders were slightly younger and had marginally lower leg-pain and ODI scores at baseline. If younger age is associated with greater sexual activity expectations and larger postoperative gains, their exclusion could bias effects downward. Conversely, because responders started with higher pain/ODI (greater scope to improve), restricting analyses to responders could inflate the observed improvement. Given the small baseline imbalances, the net direction and magnitude of any bias are uncertain. Finally, outcomes were assessed at one year, and we did not analyse reoperation status. Recurrent herniation, epidural fibrosis, or new degenerative changes beyond 12 months may affect intimacy and sexual activity. We plan future surveillance (two and five years) to capture reoperations and to evaluate the durability—or potential late decline—of improvements in ODI item 8 responses.
5. Conclusion
The sexual health of younger patients is severely affected by lumbar disc herniation and this issue is important to address for health professionals involved in the treatment of these patients. Based on this prospective cohort, surgeons can inform their patients that nearly eight out of ten report a normal or nearly normal sex life, with or without pain, one year after discectomy.
Data availability statement
The data used during the current study are available from the corresponding author upon reasonable request.
Funding
This research received no grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors have no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Handling Editor: Prof F Kandziora
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used during the current study are available from the corresponding author upon reasonable request.