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PainApr 18, 2023

Surgery for sciatica can reduce leg pain and disability for some, but the benefits are short-lived

A prominent Australia-based physiotherapist has contributed to an analysis suggesting that surgical treatments to relieve leg pain and disability in some people with sciatica yield better results than non-surgical alternatives.

The analysis – published today (19 April) in an article in The BMJ – was conducted by a team of nine that included Giovanni Ferreira, a physiotherapist by background who is based at Sydney Musculoskeletal Health, University of Sydney.

The authors supply a caveat, however, warning that the benefits of surgery may be short-lived, lasting up to 12 months. They classify the certainty of the available evidence as low to very low and suggest that surgery might only be worthwhile for those for whom the desire for rapid relief outweighs the costs and potential risks associated with surgery.

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The review offers a thorough synthesis of the evidence on surgical procedures for sciatica

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24 trials included in analysis

The team searched databases for randomised controlled trials comparing any surgical treatment with non-surgical treatment, epidural steroid injections, or placebo or sham surgery, in people with sciatica of any duration due to a herniated disk.

Pain and disability scores from the trials were converted to a 0-100-point scale, and risk of bias and certainty of evidence were assessed using recognised tools. Trial follow-up times were split into immediate term (six weeks or fewer), short term (from six weeks to three months), medium term (from three to 12 months), and long term (12 months).

A total of 24 trials were included in the main analysis, half of these looked at the effectiveness of discectomy compared with non-surgical treatment or epidural steroid injections (1,711 participants). Very low to low certainty evidence showed that discectomy, compared with non-surgical treatment, reduced leg pain. The effect size was moderate at immediate and short term (average of around 12 points lower on the pain scale), small at medium term (6.5 points lower), and negligible at long term (2.3 points lower). For disability, small, negligible, or no effects were found.

A 'comprehensive synthesis of the evidence'

A similar effect on leg pain was found when comparing discectomy with epidural steroid injections. For disability, a moderate effect was found at short term, but no effect was observed at medium and long term. The risk of any adverse events, such as wound infection, repeat disc herniation, and persistent postsurgical pain, was similar between discectomy and non-surgical treatment.

The review provides the most comprehensive synthesis of the evidence on surgical procedures for sciatica to date. But the researchers acknowledge that the certainty of evidence ranged from low to very low, that reporting of non-surgical treatments was generally poor, and that the included studies varied in the way they identified patients eligible for surgery which, alongside other limitations, may have affected the findings.

As such, they say generally, discectomy resulted in faster relief in pain and disability, but only up to 12 months – and might be considered an early management option in people in whom the benefits of early improvement in leg pain or disability outweigh the costs and potential risks.

Physios contribute to linked editorial 

Solving the heterogeneity puzzle is the key to helping people with sciatica and clinicians choose the right treatment for them earlier in the disease trajectory, while being fully informed of the benefits and risks of surgery [Annina Schmid et al]

A team led by specialist musculoskeletal physiotherapist Annina Schmid from the Nuffield Department of Clinical Neurosciences at Oxford University wrote an editorial linked to the article. This suggests that the article’s conclusions should be limited to those people with sciatica who have not responded adequately to non-surgical approaches or have severe pain and who have a surgical indication on an MRI scan. Fortunately, the majority of people with sciatica recover spontaneously without the need for surgery.

Dr Schmid and her three colleagues – two of whom are physios (Lucy Dove and Lucy Ridgway) – say the findings also highlight one of the main obstacles to improving outcomes in this clinical field: that sciatica is a heterogeneous condition, and no routine clinical measures can predict outcomes on a consistent basis.

‘Solving the heterogeneity puzzle is the key to helping people with sciatica and clinicians choose the right treatment for them earlier in the disease trajectory, while being fully informed of the benefits and risks of surgery,’ they conclude.

What is sciatica?

The term refers to pain that travels along the path of the sciatic nerve, from the lower back and down the leg. In some people, sciatica occurs when a herniated – or ‘slipped’ – disk puts pressure on or irritates the small roots of the nerve in the back.

Guidelines recommend surgery (discectomy) when non-surgical options such as drugs or steroid injections are unsuccessful. And while surgery is widely used, evidence for its use is still uncertain and recent reviews on this topic have several shortcomings.
To access the full version of the article – titledSurgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials doi: 10.1136/bmj-2022-070730 – click

To access the full version of the editorial – titled Early surgery for sciatica doi: 10.1136/bmj.p791 – click 

 

Author: Ian A McMillan
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