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Surgery versus long-term conservative treatment for sciatica

26-06-2018
N Engl J Med 2007. Wilco C. Peul, M.D.

Sciatica is characterized by radiating pain in a part of the leg that is typically served by one nerve root in the lumbar or sacral spine; sometimes also associated with sensory and motor deficiencies. A hernia is the most common cause of sciatica. In western countries, the estimated annual incidence of sciatica is 5 cases per 1,000 adults. Lumbar discectomy is often performed in patients with sciatica that does not disappear within 6 weeks, but the optimal timing of surgery is not known.

The study randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks until an early operation or prolonged conservative treatment with, if necessary, surgery. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual analogue scale for leg pain and the patient's report on observed recovery during the first year after randomization. To estimate the outcome curves for both groups, the repeated measures analysis was used according to the intention-to-treat principle.

After an average of 2.2 weeks of 141 patients undergoing early surgery, 125 (89%) had a microdisectomy. After an average of 18.7 weeks, 55 (39%) of the 142 patients designated for conservative treatment were treated surgically. During the first year, there was no significant general difference in disability scores (P = 0.13). Relief of pain in the leg grew faster for patients who were assigned to an early operation (P <0.001). Patients assigned to early surgery also reported a higher rate of observed recovery (hazard ratio, 1.97, 95% confidence interval, 1.72 to 2.22, P <0.001). In both groups, the chance of recovery observed after 1 year of follow-up was 95%.

The 1-year results were similar for patients assigned to early surgery and those assigned to conservative treatment with possibly a surgical procedure. However, for the observed recovery and the degree of pain, the operated group showed a faster recovery. This was scheduled within 2 weeks of allocation and was only canceled if spontaneous recovery took place before the date of the operation.

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