Surgery versus Prolonged Conservative Treatment for Sciatica

TLDR

Lumbar‑disk surgery is commonly performed for sciatica that persists beyond six weeks, yet the optimal timing of surgery remains unclear. This randomized trial compared early surgery with prolonged conservative treatment that allows delayed surgery if needed. A total of 283 patients with severe sciatica for 6–12 weeks were randomized; primary outcomes were disability, leg‑pain visual‑analogue scores, and perceived recovery over one year, analyzed by intention‑to‑treat repeated‑measures. Early surgery produced faster leg‑pain relief and perceived recovery, but disability scores and 1‑year recovery rates were similar between groups. Trial registered at ISRCTN26872154.

Abstract

Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups.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 first 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 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com]. ).