Surgery vs. Conservative Care for Persistent Sciatica

Sciatica affects up to 40% of people in their lifetime [1] and can be extremely painful and debilitating. Those with sciatica experience pain or numbness in their lower back, buttock, leg, or foot. This can also be caused by a lumbar herniated disc, degenerative disc disease, lumbar stenosis or spondylolisthesis [2]. Symptoms can include: dull pain, numbness, tingling or stabbing pain, electric shock-like feelings, and throbbing heat [1]. These symptoms may occur for hours; however, some may suffer from persistent sciatica lasting weeks, months or years [2]. 

There are two treatment options for sciatica: conservative or surgical. The former entails pain relief medications, epidural injections, electrical stimulation, acupuncture, hot and cold therapy, chiropractic care, and/or physical therapy, among others [3]. On the other hand, a more invasive approach involves surgical interventions such as a discectomy or laminectomy [3]. 

Given that 95% of patients with disc-related sciatica show no symptoms after one to twelve months without surgical intervention [5], the conservative approach is generally the first treatment option considered for the first six to eight weeks [4]. One of the most popular forms of conservative care treatment is physical therapy. A study conducted by Jewell and Riddle in 2005 found that of 1,804 patients with sciatica, 26% of patients had “a meaningful improvement in physical health” after undergoing physical therapy [8]. The study also found that patients who received joint mobility interventions or general exercise fared better than those who received spasm reduction interventions [8]. Another study found that those who received physical therapy showed greater improvement rates than those who did not [9]. A third study found improvement in 70% of patients with sciatica who received physical therapy at the 12-month mark [10]. While there is mixed evidence on the overall effectiveness of physical therapy, there is growing evidence of the positive effects of physical therapy as a treatment for patients with sciatica. 

However, discectomy or laminectomy surgeries are an effective option as well and have been shown to reduce recovery time by about 50% [5]. Furthermore, the rate of surgical interventions has increased over the last decade although these results vary among countries [6]. Surgery is required when the pain is opioid resistant, there is altered bladder function, or progressive muscle weakness, although these signs are rare [6]. More typically, surgery is conducted to provide more rapid pain relief [6]. 

Whether surgery or a more conservative intervention is a better treatment approach for persistent sciatica is still being investigated. The studies on this subject show mixed results. In a study of 283 patients in 2008, Peul and colleagues found that early surgical intervention resulted in more rapid pain relief than those who received conservative care; however, there was no difference in outcomes at the one or two-year marks [3]. Another study found that there was no difference among the two treatments at the five-year mark [4]. Furthermore, in 2006, Osterman and colleagues found no significant difference at the two-year mark between surgical intervention and conservative care in back or leg pain, health-related quality of life, or subjective disability [7]. They did find moderate evidence for a short-term difference in pain relief in those who received a discectomy [7]. These findings indicate that there may be some evidence for short-term pain relief for those who undergo early surgical intervention, but the long-term effects of the conservative care approach appear similar to those of surgery. 

References

[1] Harvard Health Publishing. (2016, February). Sciatica: Of all the nerve. Harvard Health. https://www.health.harvard.edu/pain/sciatica-of-all-the-nerve.

[2] Sciatica – Symptoms and causes. (2020, August 1). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/sciatica/symptoms-causes/syc-20377435.

[3] Peul, W. C., Hout, W. B. van den, Brand, R., Thomeer, R. T. W. M., & Koes, B. W. (2008). Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ, 336(7657), 1355–1358. https://doi.org/10.1136/bmj.a143.

[4] Vroomen, Patrick & de Krom, Marc & Slofstra, Patty & Knottnerus, J. (2001). Conservative Treatment of Sciatica: A Systematic Review. Journal of spinal disorders. 13. 463-9. https://doi.org/10.1097/00002517-200012000-00001.

[5] Legrand, E., Bouvard, B., Audran, M., Fournier, D., & Valat, J. P. (2007). Sciatica from disk herniation: Medical treatment or surgery? Joint Bone Spine, 74(6), 530–535. https://doi.org/10.1016/j.jbspin.2007.07.004

[6] Valat, J.-P., Genevay, S., Marty, M., Rozenberg, S., & Koes, B. (2010). Sciatica. Best Practice & Research Clinical Rheumatology, 24(2), 241–252. https://doi.org/10.1016/j.berh.2009.11.005.

[7] Österman, H., Seitsalo, S., Karppinen, J., & Malmivaara, A. (2006). Effectiveness of Microdiscectomy for Lumbar Disc Herniation. Spine, 31(21), 2409–2414. https://doi.org/10.1097/01.brs.0000239178.08796.52.

[8] Jewell, D. V., & Riddle, D. L. (2005). Interventions That Increase or Decrease the Likelihood of a Meaningful Improvement in Physical Health in Patients With Sciatica. Physical Therapy, 85(11), 1139–1150. https://doi.org/10.1093/ptj/85.11.1139.

[9] Luijsterburg, P. A. J., Verhagen, A. P., Ostelo, R. W. J. G., van den Hoogen, H. J. M. M., Peul, W. C., Avezaat, C. J. J., & Koes, B. W. (2008). Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. European Spine Journal, 17(4), 509–517. https://doi.org/10.1007/s00586-007-0569-6.

[10] Adriana, C., & Nicoleta, M. M. (2012). Effects of physical therapy in patients with sciatica. ARS Medica Tomitana, 18(4), 174–178. https://doi.org/10.2478/v10307-012-0032-8.