Published on February 28, 2008
Gen Med Morning Report: Gen Med Morning Report Sciatica Surgical vs Medical Management Ritu Khanna Frank Chen 6.6.07 Sciatica: Sciatica 5/1000 Incidence in Western countries, 1.5 million disk surgeries performed annually worldwide 5th in disease categories in the cost of hospital care and accounts for a higher cost resulting from absenteeism from work and disability than any other An art: no consensus as to how long to “prolong” conservative treatment. Important to appreciate the burden to the patient Surgery vs Prolonged Conservative Treatment for Sciatica: NEJM, 5/31/07: Surgery vs Prolonged Conservative Treatment for Sciatica: NEJM, 5/31/07 A Loaded Title? “Prolonged” Overview Methods Patients Results Discussion Method: Method Multicenter, prospective, randomized trail among patients with 6-12 wks of severe sciatica to compare early surgery vs conservative treatment for 6 months followed by surgery for those who do not have improvement The patients: The patients 283 patients, 18-65 yo, ‘02-’05 Radiologically confirmed disk herniation Dx from attending neurologist of an incapacitating lumbosacral radicular syndrome that had lasted for 6-12 wks Independent research nurse verified persistence of symptoms at time of enrollment For control, eliminated those with cauda equina, muscle paralysis, previous surgery, pregnancy, other coexisting disease Strength: Many measures to ensure active disease at time of randomization. Control over subjective qualities. Treatment Groups: Treatment Groups Early surgery scheduled within 2 weeks after assignment, again checked for symptoms prior to surgery Removal of disk hernation by minimal unilateral transflaval approach with magnification Goal of surgery: decompression of nerve root Rehabilitation at home with physiotherapists GPs provided prolonged conservative treatment to the patients. Pain control aimed at enabling patients to resume daily activities If persisted >6 mo, surgery was offered If leg pain was increasing, not responsive to medication, or if neurologic deficits progressed, surgery was offered earlier than 6 mo Slide8: Refocusing our Perspective: Emphasis on what this means to our patients There is a large body of literature already detailing management of sciatica Assessment: Assessment Patients given Roland Disability Questionnaire for Sciatica, visual-analogue scale for leg pain, 7-point Likert self-rating scale of global perceived recovery Primary outcomes: functional disability, intensity of leg pain, global perceived recovery A look at the Questionnaire: A look at the Questionnaire Results: Results 141 patients assigned to surgery - 16 recovered prior to date 142 to conservative treatment - 55 to surgery during 1st year after median period of 14.6 weeks b/c of intractable pain Early surgery group had higher rate of recurrent sciatica leading to a second surgical intervention: 3.2% vs 1.8% 3 surgical complications: two dural tears and one wound hematoma resolved spontaneously. All achieved complete resolution of neurologic symptoms Cumulative Data from Roland Disability Questionnaire : Cumulative Data from Roland Disability Questionnaire Curve shows a separation in favor of conservative treatment initially After 4 weeks, there is better outcome noted in early-surgery group. Greatest difference at 8-12 wks But at 1 year, scores on all scales used had equal recovery rates in the two groups Results cont’d: Results cont’d Median time to recovery was markedly faster in early surgery: 4 vs 12 weeks. But both groups had similar recovery rates of 95% at 52 weeks 61% recovered quickly without surgery, but 39% continued to register high pain and disability scores Translation: If there’s no difference, why not opt for early surgery to alleviate symptoms sooner? Lastly…: Lastly… Compared to other studies: Weber study ‘83 with 10 yr followup: outcome of surgery superior at 1 yr followup, at 4 years no difference. Did exclusion of patients with “intolerable” pain have impact? Weinstein in Spine Patient Outcomes Research Trial: no difference also. But substantial crossover noted, 59% scheduled for surgery actually had surgery at variable scheduled times - highlights a design strength of this Peul study. Maybe more realistic study in that enrolled patients who had symptoms at least 6 months.