Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyJuly 2023
But low-quality evidence shows benefits decline over time.
Most sciatica is caused by herniated lumbar disks; for most cases, nonsurgical management is recommended before considering surgery. To examine the evidence supporting surgery, researchers reviewed 24 randomised trials (with 1900 participants) in which any surgical treatment for sciatica due to herniated disk (i.e. discectomy, percutaneous plasma disk decompression or chemonucleolysis) was compared with any nonsurgical management (i.e. non pharmacological, pharmacological, interventional, or placebo or sham surgery).
In 12 trials, discectomy was compared with nonsurgical management; mean duration of symptoms was at least several months in most trials. Very low- to low-certainty evidence showed that discectomy yielded moderate reduction in leg pain (12 points on a 100 point scale) immediately (less than six weeks) and in the short term (six weeks to three months), a small reduction (7 points) in the medium term (three to 12 months) and a negligible longterm (more than 12 months) effect. Discectomy yielded a small reduction in disability immediately and in the short and medium terms and had a negligible longterm effect. Trials in which discectomy was compared with epidural corticosteroid injection showed a similar pattern of declining benefits for surgery over time. A few small trials of plasma disk decompression and chemonucleolysis suggested effectiveness at some time points (with very low to low certainty).
Comment: These findings – mainly relevant to patients with subacute or chronic pain – suggest that discectomy might have initial benefits that decline over time; discectomy might be an option for such patients who are willing to accept the risks and costs of surgery. However, patients with acute intolerable radicular pain attributable to a single-level disk herniation were probably under represented in these trials. Those patients often have dramatic short-term pain relief with discectomy, although symptoms can still recur in the long term.
Bruce Soloway, MD, Associate Professor Emeritus of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
Liu C, et al. Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ 2023; 381: e070730.
This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine.