Microdiskectomy surgery is the best option for treating Sciatica that has persisted for 4 to 12 months, doctors behind a randomized study of 128 patients report. The researchers found that the intensity of leg pain dropped from a mean of 7.7 points on an 11-point scale to a mean of 2.8 points 6 months after receiving surgery, compared to a decline from 8.0 points to 5.2 points among patients who received 6 months of standardized nonoperative care instead (P<0.001). Surgery also provided a better outcome for long-suffering patients when the researchers looked at quality-of-life scores, a disability index and other measures, they report in the New England Journal of Medicine. "For those who have already endured this for 4 months or longer, they shouldn't keep waiting and should consider surgery as an option," chief author Dr. Chris Bailey of the University of Western Ontario told Reuters Health in a telephone interview. "They stand a 70% better chance that these patients will get better with surgery than without." "The results are definitely better for patients treated with surgery," Dr. Michael Stauff, an orthopedic spine surgeon and assistant professor at the University of Massachusetts Medical School, in Worcester, told Reuters Health by phone. He was not involved in the study. All the volunteers had lumbar disk herniation at the L4-L5 or L5 to S1 level. Dr. Stauff estimated that fewer than half of Sciatica patients fall into that category. Roughly 90% of patients with Sciatica caused by a lumbar disk herniation find that the problem resolves itself within 4 months. But most studies of surgery have looked at patients who have only been suffering for 3 months. Although an operation seems to offer more improvement in those cases, the advantage of surgery appears to fade within 6 to 12 months. The new study was an attempt to assess the best option if the Sciatica persists. In this case, patients had suffered with it for 4 to 12 months. Dr. Stauff said the findings reinforce what he already tells his patients. "I usually tell people that unless you're so miserable with the pain you can't walk and get around, you're better off doing non-operative things because it very likely can get better," he said. "If you can't, or after 2 or 3 months, I usually talk to them about surgery. This is definitely a study I can quote to them to back that up." Half the patients received surgery within about 3 weeks using an open or minimal-access approach with loupe or microscope assistance. The rest received non-surgical care with the option of getting the operation after 6 months if their condition wasn't improving. The non-surgical group used oral analgesics with the option of active physiotherapy and epidural glucocorticoid injection. They were seen by a specialist every 6 weeks for at least 6 months. Dr. Bailey said the new data should be particularly helpful to primary care physicians, some of whom "were of the understanding that these patients would get better without surgery. This may change practice in that they would be more willing to recommend surgery for Sciatica." One factor in the improvement may have been that the people in the surgery group received their operation at a median of 3 weeks "and it is reasonable to conclude that expeditious removal of the nerve compression minimized the potential for long-term persistence of pain," Drs. Andrew Schoenfeld and James Kang of Brigham and Women's Hospital in Boston write in a linked editorial. They note that although the study shows surgery can be beneficial in this group, "the trial 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 research team screened 376 patients for the study but 111 were excluded because their symptoms had already faded before it was time to operate. Others were excluded for different reasons or ultimately declined to participate. Eighty-one percent had leg pain, 5% had back pain and 14% had both. Seventy-three percent report numbness, 48% reported tingling and 22% had weakness. Seventy-one percent had their herniation at the L5-S1 level, and 73% had an extruded disk herniation. Thirty-four percent of the patients in the nonsurgery group ultimately received surgery two to 25 months after enrollment (median, 11 months). In addition to having less-intense leg and back pain at both the 6- and 12-month mark, the surgery patients had less disability and reported significantly greater satisfaction with their treatment. The most common adverse events were superficial wound infection (seen in three patients) and postoperative neuropathic pain (also seen in three patients). One required a second surgery. —Gene Emery Source
