Surgery versus Prolonged Conservative Treatment for Sciatica

Peul WC, van Houwelingen HC, van den Hout WB, et al., for the Leiden-The Hague Spine Intervention Prognostic Study Group.
N Engl J Med 2007;356:2245–56

Background: Lumbar-disk surgery is often performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.

Patients and Methods: 283 patients who had had severe sciatica for 6–12 weeks were randomly assigned to early surgery or to prolonged conservative treatment with surgery, if needed. Primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual analog scale for leg pain, and the patient’s report of perceived recovery during the 1st year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups.

Results: Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the 1st year (p = 0.13). Relief of leg pain was faster for patients assigned to early surgery (p < 0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72–2.22; p < 0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.

Conclusion: This study indicates that endovascular therapy is associated with significantly less morbidity, less mortality, and decreased hospital resource use at discharge, compared with conventional neurosurgical treatment for all unruptured aneurysms. Endovascular therapy, as a treatment alternative to surgical clipping, should be offered as a viable therapeutic option to all patients considering treatment of an unruptured cerebral aneurysm.

Comment

Surgery is usually offered to patients with acute neurologic deficits or with persisting sciatica after a period of conservative treatment. The length and intensity of conservative treatment vary, a common length being 6 weeks. If these patients are treated early (around 2 weeks after symptom onset), they recover twice as fast from symptoms when compared to conservative treatment. Among those randomized to conservative treatment in this study, around 40% underwent later surgery for persisting pain. However, 1 year after symptom onset, there was a similar recovery rate (95%) in both groups. Taken together, the major advantage of surgery is faster relief of symptoms. Another point arouses the neuroradiologist’s interest: there was no interaction between the success of surgery or conservative tretament and the disk morphology (sequestered or not) on MRI in this study.

(submitted June 14, 2007)

Horst Urbach, Bonn