By Pat Anson, PNN Editor
A surgical procedure called a discectomy is usually considered the treatment of last resort for people with leg pain from sciatica. Most medical guidelines only recommend a discectomy when exercise, pain medication and epidural steroid injections don’t work or provide minimal relief.
But in a meta-analysis (a study of studies) published in The BMJ,an international team of researchers found little evidence that discectomies reduce leg pain and disability. And even when they do, researchers say the benefits are usually short-lived.
Sciatica is a common condition that occurs when a herniated or slipped disk puts pressure on the lumbar nerve, causing pain, numbness and inflammation. The pain is felt on the sciatic nerve, running from the lower back down to the legs. Sciatica usually responds to non-surgical treatment, but in about 20% of cases, the pain will persist for a year or more.
Researchers looked at 24 clinical trials that looked at the effectiveness of discectomy and found “very low to low certainty evidence” that the procedure was superior to steroid injections and non-surgical treatment. Pain relief was moderate at best over the short term, and negligible after 12 months. There was also little evidence that discectomies reduce disability.
Despite those findings, researchers concluded that a discectomy might still be an early option for people with severe sciatica pain who need rapid relief. A discectomy relieves pressure on the lumbar nerve by removing a portion of the damaged disk.
“These findings challenge the notion that non-surgical treatment should always be the first line treatment for sciatica. In people with sciatica who regard rapid pain relief as an important treatment goal, and who feel that the benefits of discectomy outweigh the risks and costs, discectomy could be an early management option,” wrote lead author Chang Liu, PhD, a Research Fellow at the University of New South Wales in Sydney, Australia.
“As a result of the treatment’s invasive nature and the substantial costs of surgery, we would encourage
clinicians to discuss with their patients that discectomy can provide rapid relief of leg pain, but that
non-surgical treatment can achieve similar results, although at a slower pace and with a potential chance
of requiring delayed surgery if they do not respond to non-surgical treatment.”
Liu and his colleagues found the risk of an adverse event from surgery, such as an infection, further disk herniation or post-operative pain, was similar between a discectomy and non-surgical treatment.
But in an editorial also published in The BMJ, researchers at the University of Oxford challenged Liu’s suggestion that an early discectomy might be appropriate for people who have not explored other treatment options. Most people with sciatica recover on their own, they said, without the risks of surgery.
“In primary care, about two thirds of people with sciatica recover within two to three months without the need or even an indication for invasive treatments. Therefore, extrapolation of Liu and colleagues’ findings to a primary care population would be misleading,” said lead author Annina Schmid, PhD, an Associate Professor at Oxford Neuroscience.
“Their conclusions should be limited to people with a specific diagnosis of radicular pain with or without radiculopathy, who have likely not responded adequately to non-surgical approaches, or to people with severe pain and a large enough impact on quality of life to warrant secondary care referral.”
Schmid and her co-authors say the new research highlights one of the problems in treating sciatica – it’s a complex condition influenced by individual factors, and no treatment will consistently have the same results for patients.