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Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis

updated

Tags: treatment, sciatica, surgery, exercise, back pain, pain problems, spine, butt, hip, self-treatment

One article on PainSci cites Fernandez 2016: A Guide to Sciatica Treatment for Patients

PainSci summary of Fernandez 2016: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided at the bottom of the page, as often as possible.

Based on a review of twelve mediocre trials, surgery for disc herniation causing sciatica is only a modestly superior treatment to physical activity and only in the short term; in the long term, there’s no important difference. Surgery for stenosis and spondylolisthesis was more decisively superior to exercise in the short and long term, but this good news still cannot be trusted. We need to take any seemingly good news about surgery with a grain of salt. Conclusions based on anything less than data from placebo-controlled trials is highly suspect, as shown ad nauseum about several other orthopedic surgeries (see Louw et al and related papers). This good-ish news is mostly based on comparative benefits, patient reported outcomes, and cost analyses … and that’s just not good enough anymore. Garbage in, garbage out!

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

PURPOSE: Previous reviews have compared surgical to non-surgical management of sciatica, but have overlooked the specific comparison between surgery and physical activity-based interventions.

METHODS: Systematic review using MEDLINE, CINAHL, Embase and PEDro databases was conducted. Randomised controlled trials comparing surgery to physical activity, where patients were experiencing the three most common causes of sciatica-disc herniation, spondylolisthesis and spinal stenosis. Two independent reviewers extracted pain and disability data (converted to a common 0-100 scale) and assessed methodological quality using the PEDro scale. The size of the effects was estimated for each outcome at three different time points, with a random effects model adopted and the GRADE approach used in summary conclusions.

RESULTS: Twelve trials were included. In the short term, surgery provided better outcomes than physical activity for disc herniation: disability [WMD -9.00 (95 % CI -13.73, -4.27)], leg pain [WMD -16.01 (95 % CI -23.00, -9.02)] and back pain [WMD -12.44 (95 % CI -17.76, -7.09)]; for spondylolisthesis: disability [WMD -14.60 (95 % CI -17.12, -12.08)], leg pain [WMD -35.00 (95 % CI -39.66, -30.34)] and back pain [WMD -20.00 (95 % CI -24.66, -15.34)] and spinal stenosis: disability [WMD -11.39 (95 % CI -17.31, -5.46)], leg pain [WMD, -27.17 (95 % CI -35.87, -18.46)] and back pain [WMD -20.80 (95 % CI -25.15, -16.44)]. Long-term and greater than 2-year post-randomisation results favoured surgery for spondylolisthesis and stenosis, although the size of the effects reduced with time. For disc herniation, no significant effect was shown for leg and back pain comparing surgery to physical activity.

CONCLUSION: There are indications that surgery is superior to physical activity-based interventions in reducing pain and disability for disc herniation at short-term follow-up only; but high-quality evidence in this field is lacking (GRADE). For spondylolisthesis and spinal stenosis, surgery is superior to physical activity up to greater than 2 years follow-up. Results should guide clinicians and patients when facing the difficult decision of having surgery or engaging in active care interventions.

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