Surgery Cuts Chronic Sciatica Pain vs Conservative Treatment

Damian McNamara

March 18, 2020

Surgery is superior to conservative treatment for chronic sciatica caused by lumbar disc herniation, new research shows.

Results of a prospective, randomized trial show patients with sciatica pain because of disc herniation that lasted for 4 months or more and who underwent lumbar surgery reported less pain than their counterparts who received conservative treatment.

"My take-home message is that, unlike acute sciatica, chronic sciatica is much less responsive to nonoperative treatment, and with surgery it is 70% more likely to significantly improve," lead investigator Chris S. Bailey, MD, associate professor of surgery at the Western University Bone and Joint Institute in London, Ontario, Canada, told Medscape Medical News.

"This finding was not surprising to us. It was our experience that surgery was more effective than nonoperative care in this population," he added.

The study was published online March 18 in the New England Journal of Medicine.

Study Details

Previous research points to resolution of symptoms of acute lumbar disk herniation sciatica in up to 90% of patients within 4 months with conservative treatment, the researchers note.

Other studies show short-term benefit of surgery versus medical care for acute sciatica, but "outcomes with these two approaches are similar by 6 to 12 months."

The picture for patients living with chronic sciatica is less clear. In general, previous studies only included patients with symptoms for 3 months or less, but the question of which approach is superior in patients with persistent pain remained unanswered.

For the study, investigators randomized 64 patients with chronic sciatica to receive surgery and another 64 participants to nonsurgical management for 6 months.

Participants were a mean age of 38 years and 41% were women. All participants had MRI evidence of posterolateral disk herniation at L4-L5 or L5-S1, as well as related nerve compression.

Consecutive patients were referred to specialists at a single center, including one neurosurgeon and four orthopedic surgeons, between February 2010 through August 2016.

Conservative treatment included patient education, oral analgesics, epidural glucocorticoid injections, and physiotherapy, as warranted. Patients in this group could opt for surgery after 6 months, which, the researchers note, is shorter than typical surgical wait times at their institution.

At baseline, mean leg-pain intensity scores were similar between groups, 7.7±2.0 in the surgical cohort and 8.0±1.8 in the nonsurgical cohort.

However, at 6 months, the score for leg-pain intensity was 2.8±0.4 in the surgical group and 5.2±0.4 in the nonsurgical group. This 2.4-point differential in the primary outcome had a 95% CI of 1.4 to 3.4 and was significant (P < .001).

The investigators found the mean leg-pain intensity score at 1 year remained lower in the surgery group, at 2.6±0.4, compared with 4.7±0.4 in the nonsurgical group.

Results were reported as an intent-to-treat analysis. A total of 56 patients in the surgical group underwent discectomy as planned. Seven patients canceled surgery, citing a reduction in symptoms, and one patient was unsuitable for surgery because of cardiac arrhythmia.

About one third of the nonsurgical group, 22 participants or 34%, crossed over and had surgery at a median of 11 months from baseline enrollment.

Superficial wound infection and postoperative, new-onset neuropathic pain were the most common adverse events in patients who had surgery. One patient in the surgery group experienced recurrent disk herniation and had a second operation 250 days after initial surgery.

Whether to prescribe surgery or conservative treatment in these persistent sciatica patients "is controversial because a longer duration of symptoms has been correlated with a poorer outcome associated with lumbar discectomy in some studies," the researchers note.

Even though surgery emerged as superior at 6 months, "patients may prefer to avoid surgery if they think that nonsurgical treatment could be successful or if they anticipate a risk from surgery."

The single-center design is a potential limitation of this ongoing study.

"We will next publish on the 2-year follow-up, as well as cost-effectiveness and some predictors of outcome," Bailey said.

Strengths, Caveats

In an accompanying editorial, Andrew J. Schoenfeld, MD, and James D. Kang, MD, of the Department of Orthopedic Surgery, Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts, note the superiority of discectomy in this study may be because surgery resulted in more rapid decompression of the compressed nerve root compared with conservative treatment.

However, they add that the findings are "encouraging" and the results show surgery results in "clinically meaningful improvement" in patients with persistent sciatica.

Nevertheless, they point out that the study does "not help clinicians determine which patients are most likely to benefit from immediate surgical intervention or the duration of nonoperative care that is acceptable before surgery is recommended."

The editorialists go on to note that the study design did not take into account the size of the disc herniation or extent of nerve root compression.

They add that the results "may also not be generalizable to health systems such as the one in which we practice, which allows [if not encourages] patients to influence the timing of surgery," with some opting for immediate surgery and others expressing a preference to wait.

Bailey has reported no relevant financial relationships. The study was supported by a grant from the Physicians' Services Incorporated Foundation.

N Engl J Med. Published online March 18, 2020. Abstract, Editorial

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