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      Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review

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          Abstract

          The effectiveness of surgery in patients with sciatica due to lumbar disc herniations is not without dispute. The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation. A comprehensive search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to October 2009. Randomised controlled trials of adults with lumbar radicular pain, which evaluated at least one clinically relevant outcome measure (pain, functional status, perceived recovery, lost days of work) were included. Two authors assessed risk of bias according to Cochrane criteria and extracted the data. In total, five studies were identified, two of which with a low risk of bias. One study compared early surgery with prolonged conservative care followed by surgery if needed; three studies compared surgery with usual conservative care, and one study compared surgery with epidural injections. Data were not pooled because of clinical heterogeneity and poor reporting of data. One large low-risk-of-bias trial demonstrated that early surgery in patients with 6–12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years. Another large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care.

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          Most cited references12

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          Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort.

          For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care. To compare the treatment effects of diskectomy and usual care. Prospective observational cohort of surgical candidates with imaging-confirmed lumbar intervertebral disk herniation who were treated at 13 spine clinics in 11 US states and who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003. Standard open diskectomy vs usual nonoperative care. Changes from baseline in the Medical Outcomes Study Short-Form Health Survey (SF-36) bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons/MODEMS version). Of the 743 patients enrolled in the observational cohort, 528 patients received surgery and 191 received usual nonoperative care. At 3 months, patients who chose surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6-19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences narrowed somewhat at 2 years: bodily pain (mean change: surgery, 42.6 vs nonoperative care, 32.4; treatment effect, 10.2; 95% CI, 5.9-14.5), physical function (mean change: surgery, 43.9 vs nonoperavtive care 31.9; treatment effect, 12.0; 95% CI; 7.9-16.1), and Oswestry Disability Index (mean change: surgery -37.6 vs nonoperative care -24.2; treatment effect, -13.4; 95% CI, -17.0 to -9.7). Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously. clinicaltrials.gov Identifier: NCT00000410.
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            Sciatica.

            Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptomatic. Tumour necrosis factor-alpha (TNF-alpha) is a key mediator in animal models, but its exact contribution in human radiculopathy is still a matter of debate. Sciatica is mainly diagnosed by history taking and physical examination. In general, the clinical course of acute sciatica is considered to be favourable. In the first 6-8 weeks, there is consensus that treatment of sciatica should be conservative. We review and comment on the levels of evidence of the efficacy of patient information, advice to stay active, physical therapy analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), epidural corticosteroid injections and transforaminal peri-radicular injections of corticosteroid. There is good evidence that discectomy is effective in the short term. but, in the long term, it is not more effective than prolonged conservative care. Shared decision making with regard to surgery is necessary in the absence of severe progressive neurological symptoms. Although the term sciatica is simple and easy to use, it is, in fact, an archaic and confusing term. For most researchers and clinicians, it refers to a radiculopathy, involving one of the lower extremities, and related to disc herniation (DH). As such, the term 'sciatica' is too restrictive as nerve roots from L1 to L4 may also be involved in the same process. However, even more confusing is the fact that patients, and many clinicians alike, use sciatica to describe any pain arising from the lower back and radiating down to the leg. The majority of the time, this painful sensation is referred pain from the lower back and is neither related to DH nor does it result from nerve-root compression. Although differentiating the radicular pain from the referred pain may be challenging for the clinician, it is of primary importance. This is because the epidemiology, clinical course and, most importantly, therapeutic interventions are different for these two conditions. It should, however, be emphasised that the quality of the available evidence is rather limited due to a considerable heterogeneity in the study populations included in the trials. This makes generalisation of findings across studies, and to routine clinical practice, a challenge. Prevalence estimates of radicular pain related to DH also vary considerably between studies, which is, in part, due to differences in the definitions used. A recent review showed that the prevalence of sciatic symptoms is rather variable, with values ranging from 1.6% to 43%. If stricter definitions of sciatica were used, for example, in terms of pain distribution and/or pain duration, lower prevalence rates were reported. Studies in working populations with physically demanding jobs consistently report higher rates of sciatica compared with studies in the general population. Copyright 2009. Published by Elsevier Ltd.
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              Conservative treatment of sciatica: a systematic review.

              Most patients with sciatica (often caused by disc herniations) are managed conservatively at first. The natural course seems to be favorable. The additional value of many conservative therapies remains controversial. Because a systematic review of the conservative treatment of sciatica is lacking, such a review was carried out. After a standardized literature search and selection procedure, methodology and outcome of randomized controlled trials (RCTs) were assessed by three observers. If possible, trial results were statistically pooled (= metaanalysis). The 19 RCTs that were selected showed greatly varying methodologic quality. Pooled odds ratios were calculated for several treatment types. Neither traction, exercise therapy, nor drug therapy was unequivocally effective. Epidural steroids may be beneficial for subgroups of nerve root compression. The literature suggests possible effectiveness of epidural steroids for sciatica. The authors recommend trials to investigate this treatment option further, especially with regard to patient subgroups (e.g., acute sciatica). The effects of clinical heterogeneity and methodology on review results are illustrated.
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                Author and article information

                Contributors
                +31-6-14368681 , +31-71-5266987 , w.c.h.jacobs@lumc.nl
                Journal
                Eur Spine J
                European Spine Journal
                Springer-Verlag (Berlin/Heidelberg )
                0940-6719
                1432-0932
                15 October 2010
                15 October 2010
                April 2011
                : 20
                : 4
                : 513-522
                Affiliations
                [1 ]Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands
                [2 ]Department of Health Sciences, Faculty of Earth and Life Science, EMGO Institute for Health and Care Research, VU University, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
                [3 ]Department of Epidemiology and Biostatistics, EMGO-Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
                [4 ]Department of Neurosurgery, Medical Center Haaglanden, Lijnbaan 32, 2512 VA The Hague, The Netherlands
                [5 ]Department of General Practice, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
                Article
                1603
                10.1007/s00586-010-1603-7
                3065612
                20949289
                3561a3a8-2a9d-4368-aa82-67216da270e4
                © The Author(s) 2010
                History
                : 23 July 2010
                : 22 September 2010
                : 29 September 2010
                Categories
                Review Article
                Custom metadata
                © Springer-Verlag 2011

                Orthopedics
                discectomy,surgery,systematic review,sciatica,conservative treatment
                Orthopedics
                discectomy, surgery, systematic review, sciatica, conservative treatment

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