Sciatica: Immediate Surgery or Watchful Waiting?

Article from NEJM Journal Watch Longer-Term Follow-Up from a Sciatica Trial Review of Long-Term Follow-Up Results of a Sciatica Trial Author: Allan S.
Brett, MD Differences in Outcomes Between Surgery and Nonsurgical Groups decreased during the two-year follow-up
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In a recent randomized trial, 128 patients with sciatica, L4-L5 or L5-S1 level disc herniation and nerve root compression, and pain in one leg for 4 to 12 months were randomized into two groups.
Undergoing microscopic lumbar discectomy and conservative management (NEJM JW Gen Med Apr 15 2020 and N Engl J Med 2020;382:1093)
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Leg pain was significantly less in the discectomy group than in the conservative treatment group at 1 year (mean difference, 2.
1 points on a 0-10 scale), although the condition of both groups decreased over time.

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Now, the researchers provide more follow-up data
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In the intention-to-treat analysis at 2 years, the mean difference in leg pain scores (the primary outcome) narrowed to 1.
3 points, a difference that was statistically significant but only borderline clinically significant
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Significant differences in secondary outcomes (eg, disability index) at 1 year (surgery versus conservative treatment) also narrowed or became less significant
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At 2 years, approximately one-third of patients in the conservative treatment group underwent surgery across the groups
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Although 30% of patients were lost to follow-up, sensitivity analyses suggested that, under the most plausible assumptions, these missing patients would not materially affect outcomes
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Commentary In patients with disc-related sciatica who have been ill for several months to 1 year, microscopic lumbar discectomy initially reduces pain compared with conservative management
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However, patients in the non-surgical group also experienced less disease over time
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The results suggest that discectomy should be considered in patients with unbearable or unacceptable sciatica that persists for several months, while "watchful waiting" therapy is reasonable in patients with tolerable pain
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Reviewed article Bailey CS et al.
Discectomy compared with standardized nonoperative care for chronic sciatica due to a lumbar disc herniation: A secondary analysis of a randomized controlled trial with 2-year follow-up.
J Bone Joint Surg Am 2021 Dec 1; 103 :2161.
(https://doi.
org/10.
2106/JBJS.
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