SURGERY VERSUS PROLONGED CONSERVATIVE TREATMENT FOR SCIATICA

▸ Peul WC, van Houwelingen HC, van den Hout WB, et al. NEJM 2007;356:2245–56.

Background:

The optimal timing of surgery for patients with sciatica is not known.

Research question/s:

Does early surgery (microdiscectomy) result in better and earlier outcomes (pain, and disability) in patients with severe sciatica?

Methodology:

Subjects: 283 patients (18–65 years) with severe sciatica and radiologically confirmed disc herniation (6–12 weeks’ duration) from nine centres

Experimental procedure: In a randomised fashion, subjects were assigned to receive either early surgery (SURG = 141) or prolonged conservative treatment with surgery if needed (CONS = 142). Functional disability (Roland Disability Questionnaire), leg pain (VAS 0-100), and perceived global recovery (from patients) were assessed at 2, 4, 8, 12, 26, 38, and 52 weeks. Other secondary outcomes were assessed at 8, 26, and 52 weeks.

Primary measures of outcome: Roland Disability Questionnaire (score), VAS, global patients rating.

Main finding/s:

Surgery: 125 (89%) of the SURG group underwent surgery (after mean of 2.2 weeks) and 55 (39%) of the CONS underwent surgery (after a mean of 18.7 weeks).

Disability: After 1 year, there was no significant difference in disability scores between the two groups (p = 0.13).

Patients assessed recovery: Perceived recovery was significantly faster in the SURG group (HR = 1.97; 95% CI =  1.72 to 2.22; p<0.01).

In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%. …