Surgery versus prolonged conservative treatment for sciatica

June 7, 2007

N Engl J Med. 2007 May 31;356(22):2245-56.

Comment in:

N Engl J Med. 2007 May 31;356(22):2239-43.

Surgery versus prolonged conservative treatment for sciatica.

Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA,

Tans JT, Thomeer RT, Koes BW; Leiden-The Hague Spine Intervention

Prognostic Study Group.

Department of Neurosurgery, Leiden University Medical Center,

Leiden, The Netherlands. w.c.peul@...

BACKGROUND: 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.

METHODS: 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.

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 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%.

CONCLUSIONS: 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].)

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