June 1, 2007 — Early surgery for severe sciatica may relieve pain faster than conservative treatment with eventual surgery if needed, but 1-year outcomes are similar, according to the results of a randomized trial published in the May 31 issue of The New England Journal of Medicine. Another study reported in the same issue shows that patients with degenerative spondylolisthesis and spinal stenosis who undergo surgery have better outcomes during a 2-year period compared with those who do not have surgery.
"Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known," write Wilco C. Peul, MD, from the Leiden University Medical Center in the Netherlands, and colleagues for the Leiden–The Hague Spine Intervention Prognostic Study Group. "Since the first successful surgical treatment in 1934, the international consensus has been that surgery should be offered only if symptoms persist after a period of conservative treatment. There is, however, no consensus on how long conservative therapy should be tried before surgery is considered."
The investigators randomized 283 patients with severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The main endpoints were the score on the Roland Disability Questionnaire for Sciatica, the score on the visual analog scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Analysis was by intent-to-treat, and repeated measures were used to estimate the outcome curves for both groups.
Of 141 patients randomized to the early surgery group, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients randomized to the conservative treatment group, 55 (39%) received surgery after a mean of 18.7 weeks.
During the first year, disability scores were similar in both groups (P = .13). However, the early surgery group had faster relief of leg pain (P < .001) and faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 - 2.22; P < .001). In both groups, the probability of perceived recovery after 1 year of follow-up was 95%.
"The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery," the authors write.
Study limitations include limited generalizability because patients assigned to conservative therapy were guided by research nurses who participated in pain management, inability to blind the patients and the nurses to the treatment assignment, and time until recovery being determined from examinations performed only at predefined times during follow-up.
"Our findings suggest that patients are more likely to choose surgery if they are not able to cope with leg pain, find the natural course of recovery from sciatica unacceptably slow, and want to minimize the time to recovery from pain," the authors conclude. "Patients whose pain is controlled in a manner that is acceptable to them may decide to postpone surgery in the hope that it will not be needed, without reducing their chances for complete recovery at 12 months. Although both strategies have similar outcomes after 1 year, early surgery remains a valid treatment option for well-informed patients."
The Netherlands Organisation for Health Research and Development (ZonMW) and the Hoelen Foundation, The Hague, supported this study. The authors have disclosed no relevant financial relationships.
"For patients with persistent sciatica, there seems to be a reasonable choice between surgical and nonsurgical treatment, which may be influenced by aversion to surgical risks, the severity of symptoms, and willingness to wait for spontaneous healing," Richard A. Deyo, MD, MPH, from the University of Washington in Seattle, writes in an accompanying perspective article. "Since patients who underwent surgery months after entering the study did as well as those who had surgery within 2 weeks, there does not seem to be a therapeutic window that closes quickly."
N Engl J Med. 2007;356:2239-2243, 2245-2256.
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