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Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial


Tags: surgery, sciatica, manual therapy, back pain, treatment, pain problems, spine, butt, hip

Two articles on PainSci cite Peul 2008: (1) A Guide to Sciatica Treatment for Patients(2) Complete Guide to Low Back Pain

PainSci summary of Peul 2008: ?This page is one of thousands in the 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.

Almost 300 cases of sciatica were treated and tracked for two years. Half had early surgery, and the other half started with conservative therapy 62 eventually decided to get surgery. There was no overall difference between these strategies: those who went directly into surgery did better for just a few weeks, but by after eight weeks everyone felt about the same, and 20% of all patients were still unsatisfied after two years, regardless of which path they took.

In other words, for your trouble of getting cut open, you get a modest dip in pain in the early days, but soon after, you’re back in the same boat as the fellow who didn’t bother. “Neither treatment is clearly preferable,” the researchers concluded. They argued that it might be time to stop recommending surgery based on physician preferences, and start asking patients what they think of the options.

~ 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.

OBJECTIVES: To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.

DESIGN: Randomised controlled trial.

SETTING: Nine Dutch hospitals.

PARTICIPANTS: 283 patients with 6-12 weeks of sciatica.

INTERVENTIONS: Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.

MAIN OUTCOME MEASURES: Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.

RESULTS: Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between areas under the curves over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.

CONCLUSIONS: Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.

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