Comparing Surgical Intervention to
Extended Non-Surgical Management for Sciatica

Sciatica arises from nerve compression in the lower back, leading to leg pain. A common cause is a herniated disk, impacting approximately 5 in every 1000 adults each year.

The condition has notable economic consequences and typically responds well to conservative treatment within 8 weeks. Surgical intervention is only contemplated if symptoms persist despite non-surgical approaches.

However, the most effective timing for surgery remains uncertain. This study investigates the effectiveness of early surgical intervention compared to prolonged conservative care for individuals experiencing severe sciatica.

A multicenter, randomized trial compared the outcomes of early surgical intervention and prolonged conservative treatment for sciatica. The study found that while patients who underwent early surgery experienced faster symptom relief, there was no significant difference in overall functional recovery after one year when compared to those who received conservative treatment with the option of subsequent surgery.

During the 12-month period, a higher percentage of patients in the early-surgery group (89%) underwent microdiscectomy compared to the conservative-treatment group (39%).

At the one-year follow-up, there were no significant disparities between the two groups in various outcome measurements, including the level of leg pain. Therefore, the primary advantage of early surgical intervention appears to be the prompt alleviation of sciatica symptoms

Initially, opting for early surgery may lead to a slower recovery of daily functioning compared to conservative treatment because of the use of standard microdiscectomy techniques.

However, as time progresses, the pace of recovery improves, and there is no significant disparity in overall recovery rates within the first year between the two treatment approaches. The Roland Disability Questionnaire scores did not indicate any clinically superior outcomes with early surgery.

While leg pain relief was quicker in the early surgery group, the discrepancies in pain scores were minimal, and by the one-year mark, the scores were nearly identical.

Surgery consistently showed advantages in terms of speedy recovery and pain relief for most patient subgroups, with the exception of those whose sciatica was not triggered by sitting.

However, this particular subgroup constituted a small portion (24%) of the patients. The ability to sit without pain had a significant impact on daily functioning.

Surprisingly, there were no notable interactions observed between the assigned treatment and factors such as Lasègue’s sign, pain intensity, presence of disk sequestrations, or patient preferences for treatment.

Multiple studies since 1934 have confirmed the success of surgical treatment for sciatica. In a landmark trial by Weber, surgery initially showed superior outcomes compared to conservative care at the 1-year mark, but the difference disappeared after 4 years. Similarly, a randomized study comparing surgery to corticosteroid use revealed early advantages for surgical intervention.

Weinstein et al.’s study (SPORT) comparing surgery to conservative treatment for sciatica failed to show any advantage of surgery in their intention-to-treat analyses.

Significant crossover occurred in both treatment groups, resulting in a small difference in surgery rates after 6 weeks. Additionally, only 59% of patients assigned to surgery actually underwent the procedure, and the timing of surgery varied widely.

Crossover from conservative treatment to surgery influenced the primary outcomes, but the differences between the groups were mitigated by early surgery in the surgical group.

About 39% of patients who did not recover quickly eventually underwent surgery. A similar trend was observed in a study by Österman et al., although their study lacked sufficient statistical power.

The financial burden of sciatica, primarily due to productivity loss, is significant. Globally, more than 1.5 million disk surgeries are conducted each year, yet the most favorable timing for surgery remains uncertain.

This study offers valuable insights to patients contemplating surgery, assisting them in making informed decisions about their treatment options.

Patients considering disk surgery for sciatica were provided information about the effects of early surgery and conservative treatment on disability, leg pain intensity, and recovery time.

Findings indicate that patients more likely to choose surgery are those unable to manage leg pain, dissatisfied with the natural recovery rate, and seeking faster pain relief.

Both treatment options have similar outcomes, making early surgery a viable choice for well-informed patients. However, patients with manageable pain may opt to postpone surgery without compromising their chances of complete recovery at 12 months.