Surgery to relieve leg pain and disability in some people with sciatica may be better than other non-surgical treatments, but the short-lived benefits may last only up to 12 months, according to a new analysis led by the University of Sydney, Sydney Musculoskeletal Health, and published in the journal BMJ.
The analysis also found that the certainty of available evidence is low to very low, prompting the researchers to suggest that surgery might only be a worthwhile option for people who feel that the rapid relief outweighs the costs and potential risks associated with surgery.
Sciatica 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 “slipped” or herniated disc causes irritation or pressure on the small roots of the nerve in the back.
Current treatment guidelines recommend surgery known as 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.
Solving this puzzle of why patients have different outcomes 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 key benefits and risks of surgery,
Researchers 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 disc.
Trials follow-up times were split into immediate term (six weeks or less), short term (between six weeks and three months), medium term (between three months and 12 months), and long term (12 months).
A total of 24 trials were included in the main analysis, of which half looked at the effectiveness of discectomy compared with non-surgical treatment or epidural steroid injections.
“Our analysis found that there was low to very-low certainty evidence of a moderate reduction in leg pain when we compared surgical to non-surgical treatment,” said lead author Dr Chang Liu from Sydney Musculoskeletal Health, an initiative of the University of Sydney, Sydney Local Health District and Northern Sydney Local Health District.
“However, benefits of surgery in improving leg pain diminished within 12 months. Similarly, surgery improved functional outcomes but the improvements were short-lived.”
A similar effect on leg pain was also found when comparing discectomy with epidural steroid injections. 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.
They also suggest that the conclusions from this review should be limited to people with sciatica who have not responded well to non-surgical approaches, or people who 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. However, this also poses a challenge for healthcare providers as there are no ways to reliably predict patient outcomes, the researchers note.
“Solving this puzzle of why patients have different outcomes 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 key benefits and risks of surgery,” said senior author Professor Christine Lin.