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      Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study


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          Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting.


          A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting.


          Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (−0.97; 95% CI −1.89 to −0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (−3.7; 95% CI −7.4 to −0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.


          Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.

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          Most cited references24

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          Randomized, Controlled Trials, Observational Studies, and the Hierarchy of Research Designs

          New England Journal of Medicine, 342(25), 1887-1892
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            Assessing health-related quality of life in patients with sciatica.

            This study analyzed health-related quality-of-life measures and other clinical and questionnaire data obtained from the Maine Lumbar Spine Study, a prospective cohort study of persons with low back problems. For persons with sciatica, back pain-specific and general measures of health-related quality-of-life were compared with regard to internal consistency, construct validity, reproducibility, and responsiveness in detecting small changes over a 3-month period. Data were collected from 427 participants with sciatica. Baseline in-person interviews were conducted with surgical and medical patients before treatment and by mail at 3 months. Health-related quality-of-life measures included symptoms (frequency and bothersomeness of pain and sciatica) functional status and well-being (modified back pain-specific Roland scale and Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and disability (bed rest, work loss, and restricted activity days). Internal consistency of measures was high. Reproducibility was moderate, as expected after a 3-month interval. The SF-36 bodily pain item and the modified Roland measure demonstrated the greatest amount of change and were the most highly associated with self-rated improvement. The specific and generic measures changed in the expected direction, except for general health perceptions, which declined slightly. A high correlation between clinical findings or symptoms and the modified Roland measure, SF-36, and disability days indicated a high degree of construct validity. These measures performed well in measuring the health-related quality-of-life of patients with sciatica. The modified Roland and the physical dimension of the SF-36 were the measures most responsive to change over time, suggesting their use in prospective evaluation. Disability day measures, although valuable for assessing the societal impact of dysfunction, were less responsive to changes over this short-term follow-up of 3 months.
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              Sciatica: review of epidemiological studies and prevalence estimates.

              Review of studies on sciatica prevalence and synthesis of available evidence. To assess the studies on sciatica prevalence, discuss reasons for variation in estimates, provide suggestions for improving accuracy of recording sciatica in epidemiological and outcome studies so as to enable better evaluation of natural history and treatment effect in the presence of low back pain related sciatica. Sciatica is a common cause of pain and disability. It is more persistent and severe than low back pain, has a less favorable outcome and consumes more health resources. However, sciatica prevalence rates reported in different studies and reviews vary considerably and provide no clear picture about sciatica prevalence. A literature search of all English language peer reviewed publications was conducted using Medline, EMBASE, and CINAHL for the years 1980-2006. Two reviewers extracted data on sciatica prevalence and definitions from the identified articles. Of the papers retrieved, 23 were included in the review. Only 2 studies out of the 23 used clinical assessment for assessing sciatic symptoms, and definitions of sciatica varied widely. Sciatica prevalence from different studies ranged from 1.2% to 43%. Sciatica prevalence estimates vary considerably between studies. This may be due to differences in definitions, methods of data collection and perhaps populations studied. Suggestions are made on how to improve accuracy of capturing sciatica in epidemiological studies.

                Author and article information

                BMJ Open
                BMJ Open
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                21 December 2016
                : 6
                : 12
                : e012938
                [1 ]Department of Neurosurgery, Cantonal Hospital Aarau , Aarau, Switzerland
                [2 ]Institute of Primary Health Care (BIHAM), University of Bern , Bern, Switzerland
                [3 ]Department of Rheumatology, Cantonal Hospital Aarau , Aarau, Switzerland
                [4 ]Department of Rheumatology, Stadtspital Triemli , Zürich, Switzerland
                [5 ]Applied Health Research Centre (AHRC), University of Toronto , Toronto, Ontario, Canada
                [6 ]Department of Medicine, University of Toronto , Toronto, Ontario, Canada
                [7 ]Institute of Social and Preventive Medicine (ISPM), University of Bern , Bern, Switzerland
                [8 ]Department of Rheumatology, Immunology and Allergology, Inselspital Bern University Hospital , Bern, Switzerland
                Author notes
                [Correspondence to ] Professor Paul Hasler; paul.hasler@ 123456ksa.ch

                MG and BRdC contributed equally and share first authorship.

                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                : 9 June 2016
                : 27 September 2016
                : 30 September 2016
                Rehabilitation Medicine

                surgery, conservative, hernia, prolapse, sciatica


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