Surgery’s Impact on Sciatica Symptoms Investigated

Surgical Versus Non-Surgical Treatment for Sciatica: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aim

To investigate the effectiveness and safety of surgery compared to non-surgical treatment for sciatica.

Design Systematic review and meta-analysis.

Data sources Medline, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform from database inception to June 2022.

Eligibility criteria for study selection

Randomized controlled trials comparing any surgical treatment with non-surgical treatment, epidural steroid injections or placebo or sham surgery, in patients with sciatica of any duration due to lumbar disc herniation (diagnosed by radiological imaging).

Data extraction and synthesis

Two independent reviewers extracted data. Leg pain and disability were the primary outcomes. Adverse events, back pain, quality of life, and treatment satisfaction were secondary outcomes. Pain and disability scores were converted to a scale from 0 (no pain or disability) to 100 (worst pain or disability). Data were pooled using a random effects model.

Risk of bias was assessed with the Cochrane Collaboration tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Follow-up times were immediate term (≤ six weeks), short term (> six weeks and ≤ three months), medium term (> three and < 12 months) and long term (at 12 months).

Results

We included 24 trials, half of these investigating the effectiveness of discectomy compared with non-surgical treatment or epidural steroid injections (1711 participants).

Very low to low certainty evidence showed that discectomy, compared with non-surgical treatment, reduced leg pain: the effect size was moderate in the short term (mean difference -12.1 [confidence interval 95% -23.6 to -0.5]) and in the short term (−11.7 (−18.6 to −4.7)) and small in the medium term (−6.5 (−11.0 to − 2.1)).

Negligible long-term effects were observed (-2.3 (-4.5 to -0.2)). For disability, small, insignificant, or no effects were found. A similar effect on leg pain was found when comparing discectomy with epidural steroid injections. For disability, a moderate effect was found in the short term, but no effect was observed in the medium and long term.

Comments

Sciatica can cause stabbing, unrelenting pain in the legs, and surgery is often recommended if other, less invasive measures fail to relieve it. Unfortunately, a review of a new study suggests that such operations are likely to only provide temporary results, and the pain typically returns within a year.

Sciatica is "characterized by pain down the back of the leg, most often due to pressure on a spinal nerve root caused by a ruptured spinal disc in the lower back," the author said. of the study, Christine Lin, professor of Sydney Musculoskeletal Health at the University of Sydney in Australia. "The condition can also manifest as back pain, muscle weakness and a tingling sensation in the lower leg. "We set out to investigate whether surgery was effective in relieving pain and disability in people with sciatica caused by ruptured [spinal] disc," Lin said.

But after reviewing 24 previous studies, she and her colleagues concluded that while partial removal of a ruptured disc ( diskectomy ) resulted in short-term relief from pain and disability, "the benefits diminished over time, and at one year there was no benefit from treatment compared to people who did not have surgery."

Lin noted that although surgery is not the only intervention for patients with sciatica, "we don’t have many treatment options that are supported by scientific evidence." There is only "limited evidence" to suggest that an exercise program (physical therapy) is helpful. Similarly, Lin said, there is little evidence that drugs (including steroids injected directly into the lower back) are effective in providing substantial pain relief. Many patients opt for surgery, Lin said, despite the risk of disc tears and wound complications.

To evaluate the relative effectiveness of surgery, Lin’s team reviewed two dozen studies that had previously compared the potential benefits of surgery with non-surgical options for sciatica patients whose condition was caused by a herniated disc. Half of the studies specifically examined surgical outcomes after a discectomy procedure . Nonsurgical options included steroid injections and/or sham surgery or sham treatments. Studies variously tracked pain relief results for periods of up to a year after treatment.

In the end, Lin and his colleagues determined that the evidence that discectomy surgery was more effective in reducing leg pain than non-surgical options was "very low" to "low . "

The team further noted that the evidence suggested that surgery was better than non-surgical options when it came to providing "moderate" pain relief within three months after surgery. But after three months, and up to a year later, surgery’s ability to provide better pain relief than non-surgical options was found to be relatively "small . " And no significant benefit in pain relief was seen a full year after surgery.

The team acknowledged that the studies under review were conducted under different conditions, which could affect the criteria by which patients were considered eligible for surgery. Furthermore, study discussions of non-surgical outcomes were often found to lack quality. Lin said the result of the review, published April 19 in the BMJ , "was not entirely surprising, as previous research had similar findings."

Still, he emphasized that most people with sciatica improve over time , so for many patients the short-term relief that surgery can provide "could still be worth it," if patients and surgeons decide to follow that path. path. Could some patients gain more from surgery than others? Lin said that at the moment "we don’t have enough information" to know.

But their conclusion is that "surgery could be considered as an early treatment option, which may be important for those patients for whom rapid pain relief could be a priority and who think that the short-term benefits of surgery outweigh the benefits." potential risks and costs of surgery.

Annina Schmid, co-author of an editorial published with the review, is director of the neuromusculoskeletal science and health laboratory at the Nuffield Department of Clinical Neurosciences at the University of Oxford in England.

She seconded the observation that most sciatica patients (about 7 in 10) "recover spontaneously ," regardless of whether they opt for physical therapy, medications, or surgery. "So what this study shows is that, in the long term, both surgery and conservative care provide comparable symptom relief," Schmid said.

Implications for clinical practice

International guidelines generally recommend surgical treatment for sciatica secondary to lumbar disc herniation if patients have not responded to comprehensive nonsurgical treatment. These recommendations are because many people with acute sciatica will experience improvements in their condition over time. Overall, our review supports these recommendations because it has been shown that nonsurgical treatment can lead to similar long-term outcomes or even longer follow-ups.

However, the benefits may vary between different groups of people with sciatica. Attempts have been made to specify who might benefit most from early discectomy for people with sciatica. It was shown that people with more severe leg pain and disability were more likely to have persistent and debilitating symptoms at 12 months. Therefore, this subgroup could benefit from early discectomy because our review has shown that surgical treatment could lead to a more rapid reduction in leg pain. Added to this is evidence that early discectomy is cost-effective compared to prolonged non-surgical treatment in the context of the Dutch healthcare system.

These findings challenge the notion that nonsurgical treatment should always be the first-line treatment for sciatica. In people with sciatica who consider rapid pain relief an important goal of treatment and who feel that the benefits of discectomy outweigh the risks and costs, discectomy could be an early treatment option.

As a result of the invasive nature of the treatment and the substantial costs of surgery, we encourage physicians to discuss with their patients that discectomy can provide rapid relief from leg pain, but that nonsurgical treatment can achieve similar results, albeit at a slower rate and with a potential chance of requiring late surgery if they do not respond to non-surgical treatment.