Surgery to relieve leg pain and disability in some people with sciatica may be better than other treatments but the benefits only last up to a year, a comprehensive meta-analysis has found.
But the evidence in general is not very certain suggesting that surgery may only be worthwhile in those patients who feel the symptom relief outweighs the potential risks and costs of surgery, the Australian researchers found.
Guidelines do recommend discectomy when non-surgical options such as drugs or steroid injections have failed in patients where slipped disc has cause their sciatica.
They found relevant 24 trials of surgery half of which had compared the effectiveness if discectomy with other non-surgical treatments in 1,711 patients.
Surgery did reduce leg pain, the evidence suggested, but the effect size was moderate in the short term with a 12-point reduction on the pain scale compared with other treatment options.
Between three and 12 months, this had fallen to six points on the pain scale and was a negligible difference by a year, the researchers said.
In terms of disability, small, negligible, or no effects were found when surgery and other treatments were compared, they reported in The BMJ.
A similar effect on leg pain was found when comparing discectomy with epidural steroid injections.
The risk of adverse outcomes such as wound infection, repeat disc herniation, and persistent postsurgical pain, was similar between discectomy and non-surgical treatment, the team said.
In assessing who might benefit most from surgery they noted that people with more severe pain in their leg and disability were more likely to have persistent and debilitating symptoms at 12 months.
‘Thus, this subgroup might benefit from early discectomy because our review has shown that surgical treatment might lead to faster leg pain reduction,’ they concluded.
In a linked editorial, Annina Schmid, associate professor of neuromusculoskeletal health and science said the results of the meta-analysis suggest surgery should be reserved for those with the most severe pain whose MRI scan indicates 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,’ she wrote.
‘Therefore, extrapolation of Liu and colleagues’ findings to a primary care population would be misleading.
‘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.’
