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Surgery appears to improve outcomes more than usual care in patients with sciatica for more than 4 months
Clinical Question
Is surgery more effective than conservative care for sciatica that has lasted 4 to 12 months?
Bottom line
This trial found greater improvement at 6 months in patients who were randomized to receive surgery, although the large number of late crossovers, the high rate of loss to follow-up, and the fact that patients in the nonsurgical group also experienced significant improvement at 6 months make the findings less impressive. 1a-
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Foundation
Setting: Outpatient (specialty)
Synopsis
Surgery for acute sciatica improves outcomes in the short term, but there is no difference between patients who do and do not undergo surgery at 12 months. This trial identified adults with 4 months to 12 months of unilateral sciatica and a magnetic resonance imaging lesion consistent with their symptoms at L4/L5 or L5/S1. Exclusion criteria included previous surgery, older than 60 years, and spinal stenosis. Patients were randomized to receive surgery within 3 weeks or usual care with placement on a waiting list for surgery that typically meant at least a 6-month wait in the United Kingdom. Usual care included physical therapy, oral pain medications, and, if recommended, up to 3 epidural corticosteroid injections. Of the 790 patients who were screened, 168 met the inclusion criteria and 128 agreed to participate and were randomized. The mean age was only 38 years, 41% were women, and the baseline characteristics were similar between groups. Of the 64 patients in the nonsurgical group, 2 were lost to follow-up and 22 eventually crossed over to surgery, but this occurred after 6 months. Therefore, the 6-month outcomes are the most relevant. By the time of the 6-month visit, 2 patients in each group had withdrawn and 11 in the surgical group and 8 in the nonsurgical group missed that visit, for a retention rate overall of only 82%. At 6 months the primary outcome of a 10-point self-reported leg pain intensity score had decreased significantly more in the surgical group (from 7.7 to 2.8 in the surgical group versus from 8.0 to 5.2 in the nonsurgical group). This difference of 2.4 points (95% CI 1.4 - 3.4) was both statistically and clinically significant. Improvements in secondary outcomes, such as back pain, disability score, and quality of life score, also improved significantly. Adverse events occurred in 6% of the patients in the surgery group, including superficial wound infections, neuropathic pain, and recurrent herniation. Because of the large number of patients lost to follow-up, a multiple imputation analysis was also performed and had results similar to those in the primary analysis.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA