Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

Abstract

Objectives: To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.

Design: Randomised controlled trial.

Setting: Nine Dutch hospitals.

Participants: 283 patients with 6-12 weeks of sciatica.

Interventions: Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.

Main outcome measures: Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.

Results: Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between "areas under the curves" over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.

Conclusions: Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.

Trial registry: ISRCT No 26872154.

Fig 1 Flow diagram of patients through two year study

Fig 2 Repeated measurement analysis curves of mean scores for Roland disability questionnaire (top panel) and visual-analogue scales for leg pain and back pain (lower panels)