What is the efficacy of treatments for low back pain (LBP) and sciatica?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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The recent and very ambitious Spinal Patient Outcomes Research Trial (SPORT) had been hoped to significantly clarify the surgical versus nonsurgical issues. Finding definitive answers in this study is difficult, though they contain a large amount of interesting information. For disk herniation, the major conclusion at 4 years was that nonoperative treatment or surgery led to improvement in intervertebral disk herniation. But surgery may have a slight benefit. [38, 39] For spondylolisthesis, the 2- and 4-year as-treated analysis showed an advantage to surgical therapy. [40, 41] Likewise, for spinal stenosis, the 2-year analysis showed somewhat more improvement for surgery. [42]

With regard to cost effectiveness, the surgical costs were rather high, though not completely out of the range of other medical treatments. For lumbar disk herniations, 1 quality-adjusted life year (Qaly) cost about $70,000. For stenosis and spondylolisthesis the costs per Qaly were $77,000 and $116,000, respectively. [43, 44] A significant general problem with the SPORT data is that there was so much switching between treatment groups that intention-to-treat analysis (the usual criterion standard) was impossible. Therefore as-treated analyses were used.

The study concluded in 2014 and found after 4 years of follow-up that the average surgical patient enjoys better health outcomes and higher treatment satisfaction but incurs higher costs. [45] Although this may seem nothing new, this study does represent the most extensive study of surgical vs. non-surgical outcomes ever conducted. Hopefully, future studies and newer treatments may someday provide clearer answers.

The rationale for nonoperative treatment of diskal herniation has been supported by clinical and autopsy studies, which demonstrate that resorption of protruded and extruded disk material can occur over time. [46, 47] Other studies have correlated MRI or CT improvement with successful nonoperative treatment in patients who have lumbar disk herniations and clinical radiculopathy. [47, 48, 49] The greatest reduction in size typically occurred in patients with the largest herniations. Recent uncontrolled studies have shown that patients who have definite herniated disks and radiculopathy and satisfy the criteria for surgical intervention can be treated successfully with aggressive rehabilitation and medical therapy. Good to excellent results were achieved in 83% of cervical and 90% of lumbar patients. [50, 51]

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