Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a143 (Published 12 June 2008) Cite this as: BMJ 2008;336:1355
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Sir,
The paper by Peul et al (BMJ 2008; 336: 1355-1358 (14th June, and the Editorial by Fairbank in the same issue (P1317-1318) are timely and of considerable relevance to the Health Service at present. Owing to a number of factors detailed below the current treatment of sciatica is most unsatisfactory with in the NHS.
Over the last few years it has been generally recognized that most acute episodes of back pain settle with appropriate conservative treatment, and referral to a consultant orthopaedic surgeon is not necessary. Most units have set up triage systems to which patients are referred by the General practitioner, and decision is made there concerning consultant referral or direct referral to a physiotherapy unit for treatment. These triage systems are of two types, one is set up in the Hospital Trust, and has consultant input of varying degree, the others are set up in the community, by the Primary |Care Trusts these have no continued consultant input, and indeed many are set up without any consultant involvement at all. Unfortunately the treatment pathway does not distinguish between acute back pain alone, and acute back pain with sciatica due to root compression. Hence patients with sciatica find themselves undergoing prolonged physiotherapy for sciatica without consultant referral. Doing medico-legal practice I became aware of these therapeutic disasters, seeing patients with remedial root entrapments continuing with prolonged conservative therapy, ending up in a pain clinic, registered disabled, and the loss of job of both patient and carer.
I therefore sent a fairly comprehensive questionnaire concerning the treatment of sciatica to 75 spinal surgeons to see if my impression was erroneous. I received replies from 54 surgeons. It was clear that amongst spinal surgeons there was considerable disquiet at the way the PCT triage systems functioned. Of the 54 surgeons who replied, 25 dealt with PCT Triage systems in which they had no input, and they all felt that as a result conservative treatment of sciatica. was continued overlong and patient care as a consequence was compromised. There was general support for my concerns at the last BOA Meeting in 2007, and the issue will again be raised at the coming meeting in September 2008 What is required is that sciatica is recognized in treatment protocols as quite different from acute back pain, meriting early consultant referral and an early MRI. At present in many areas a GP is not allowed to refer a patient with sciatica to a consultant directly at all.
It is questionable if physiotherapy alters the natural history of sciatica due to a disc herniation at all, (Luijsterburg J) and it is not cost effective ((Hansson E) certainly prolonged therapy has all the undesirable consequences outlined by Peul et al. It would seem appropriate that perhaps NICE should intervene and present some Guidelines for the treatment of sciatica due to a prolapsed disc.
Yours Sincerely
Professor Robert Mulholland FRCS
Emeritus Spinal Surgeon, Nottingham University Hospital
Consulting Rooms NG1 5BT
E-mail mulhollandrcm@aol.com
Luijsterburg J Verhagen an Ostelo R Van Os a Wilco C Koes B (2007) Effectiveness of conservative treatments for lumbosacral radicular syndrome: a systemic review. Eur Spine J, 16, No 7 881-899.
HANSSON E Hansson T(2007) The Cost-utility of lumbar disc herniation surgery. Eur Spine j., 16, No 3 P 329-337.
Competing interests: None declared
Competing interests: No competing interests
Dear Sir
We were shocked at your use of pseudo-medical terminology on the front cover of the BMJ on the 14th June 2008. There is NO such thing as a 'slipped disc'. The disc does not slip but prolapse and the correct terminolgy should be prolapsed intervertabral disc.
We were pleased to see that the editorial and original research paper did in fact get the terminology correct and it was only the sensationalist headline-seeking on the front cover that was inaccurate. It saddens us to see such an eminent journal being so sloppy on its terminology with its 'standards rather than the disc slipping'.
Competing interests: None declared
Competing interests: No competing interests
We thank both authors of the quick responses for their valuable comments. Dr Greenslade correctly stated that epidural corticosteroids were not applied to the conservatively treated patients in our trial. Although these might be symptom relieving for small periods of time evidence was lacking at the moment this trial was designed. As for now spinal departments prescribe corticosteroids, while results of recent studies including systematic reviews present conflicting conclusions. As it is an invasive method most physicians in our country do not routinely prescribe these injections. Yet as prolonged conservative care seems to be a valuable treatment strategy, but keeps a considerable proportion of patients suffering sciatic neuralgia for months, the option of corticosteroids should be kept open as an alternative treatment to evade surgery.
Dr. Tromanhouser is raising an intriguing point of discussion which is a debate in some scientific societies since the SPORT and the first year results of our trial have been published. In contrast to the SPORT authors our aim was to evaluate the current guideline of early surgery for sciatica and to compare the effectiveness with a strategy of prolonged conservative, including surgery when needed.
As delayed surgery was performed according to the study protocol we state that these patients were not crossovers but part of a pragmatic randomized trial comparing two strategies instead of surgical versus strict nonoperative treatment. An “intent-to-treat” analysis is in our opinion the best way to present the results but the authors certainly plan to present an as treated analysis, including a discussion of the drawbacks of the latter seemingly attractive but less rigorous methodological approach.
Competing interests: None declared
Competing interests: No competing interests
You are to be commended for undertaking a difficult study. Alas, I must agree with Dr Greenslade's opinion that this study design and treatment protocol does not reflect present day reality. In the U.S. there is tremendous "anti-surgical" bias in the medical community and patients are told to avoid surgery by their primary care providers. Most respectable surgeons would try activity modifications, physical therapy and steroid injections among other treatments before rushing someone off to the operating room in a matter of weeks. This serves to allow those who are destined to recover spontaneously to do so.
Furthermore, this study suffers from the same flaw as the SPORT trial of Weinstein et al which was originally presented with an "intent to treat" approach and was widely criticized. Peul et al had 44% of the patients in the surgical group cross-over and undergo surgery, in which case, the intent to treat analysis defies common sense. In the very least both analyses should be clearly presented and discussed.
Competing interests: None declared
Competing interests: No competing interests
Peul et al. have added useful detail to the debate on how to manage lumbar disc prolapses. Unfortunately, the two arms of their randomised control trial do not reflect current practice in specialist spinal centres in the UK. It would be more usual for patients with lower limb pain to be offered epidural steroids, either through a classical epidural injection, or via an X-ray guided nerve root block. These interventions can be markedly successful and result in patients becoming virtually pain free in the acute phase of the prolapse, making it more likely that the patient will progress to longer-term conservative care. It is public knowledge that Tony Blair underwent a steroid nerve root block whilst he was Prime Minister, without having to progress to surgery.[1] Clearly a treatment worthy of consideration at the highest level.
1 http://news.bbc.co.uk/1/hi/uk_politics/4564403.stm
Competing interests: None declared
Competing interests: No competing interests
Surgery for Sciatica - Informed Patient Decision Making is the Key
Dear Sir,
I would like to congratulate Wilco Peul and his colleagues on their attempt to provide good quality evidence which can be used to help advise patients when discussing the management of their sciatica.1 This is a common problem and it is clearly important that we have an understanding of the risks, benefits and costs of surgery.
However, I am concerned that this article may lead to some patients being denied the opportunity discuss surgery when it may be of benefit to them.
For those involved in spinal surgery it is a day to day observation that if a compressed nerve root is causing pain then decompressing the nerve root provides a very good chance of alleviating the pain. This observation is supported by the author’s results and endorsed by the 44% of patients in the conservative treatment arm who eventually underwent surgery. Results which are similar to those of the SPORT trial.2
Accepting that nerve root decompression is effective in relieving pain but that the condition of disc prolapse often resolves spontaneously, the long standing debate has been over the timing of surgery and the long term outcome.
What this paper adds is confirmation that surgery provides a good chance of rapid relief from pain and that the complication rate is low. It cannot be used to conclude that after 12 months whether you have surgery or not the outcome is likely to be the same. This is because of the very high failure rate of conservative management. Had 44% of patients not converted to surgery one has to presume that dissatisfaction with the conservative arm would have been greater.
One of the authors’ conclusions is that,” well-informed patients, rather than physicians, should decide whether and when to have surgery”. Although I am not sure what this paper provides to support the claim that it is ,”What this study adds”, I very much agree with this sentiment and would have thought it prerequisite for any surgical intervention. However, application of this principle creates an apparent contradiction with the European guidelines referred to by Mr Fairbank in his editorial.3 He reports that, “Surgery should be performed before eight weeks only in patients with progressive neurological deficit, which can be detected by magnetic resonance imaging”(sic).
Given that we have an effective treatment for radicular pain it would appear inhumane to deny a patient surgery (or the opportunity to discuss surgery or other interventions e.g. dorsal root ganglion block) should they be in significant pain. They should be the ones who decide whether the pain is of such intensity and has lastest long enough that the potential benefits of surgery outweigh the risks. This assumes that the decision is made having had a full and frank discussion of the potential risks and benefits. To this end it is imporatant limitations of published data are understood.
To have 20% of patients dissatisfied at 2 years is very disappointing. It would be interesting to know more about this group of patients. Were the reasons for dissatisfaction similar in the two groups? How many of the conservatively managed patients who were dissatisfied complained of persisting symptoms for which they had originally consulted their GP? Of those in the surgical group, how much of their dissatisfaction could be potentially attributed to recurrent or a residual nerve root compression?
I note the average length of hospital stay was 3.7 days. Since microdiscectomy is regularly performed as a day case it is difficult to understand why the length of stay was so long. It is also hard to believe that this would not have an impact on the economic considerations.
The inclusion criteria required that a patient not only describe a dermatomal pattern of pain but also demonstrated, concomitant neurological disturbances which correlated with the affected nerve root. Since the patient's primary complaint was of pain and that the surgical treatment is effective for the symptom of pain it is difficult to understand why the presence of additional neurological disturbance was required.
Although the authors report that there was no significant difference in back pain suffered by the surgical group compared with the conservatively managed group the illustrations clearly demonstrate a significant difference at the 8 and 12 week assessments. The significance of this difference may have been greater had the pain score for back pain been higher. Since some authorities will only consider operating for sciatica if the leg pain is greater than the back pain it would be interesting to know whether this criteria was employed by the authors? If this were the case, it may explain the discrepancy between their study and that recently reported by the SPORT trial.2 This reports a greater improvement in back pain following discectomy than with non-operative treatment and that this difference was maintained at two years.
It is also important to point out to the wider readership of your journal that the authors have selected to examine patients with nerve root compression secondary to an intervertebral disc prolapse. It is well known that symptoms caused by a disc prolapse are likely to improve with time. However, more patients probably suffer from nerve root compression as a result of other degenerative change in their spine such as facet hypertrophy and disc bulge. The natural history of this condition is likely to be different from that of disc prolapse. Thus, it is important that a distinction is made between the treatment of sciatica due to disc prolapse and sciatica due to other causes of nerve root compression.
Yours sincerely,
Tim Germon
1. Fairbank, J. Prolapsed intervertebral disc. BMJ, Jun 2008;336:1317 – 1318
2. Peul WC et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ Jun 2008;336:1355 – 1358.
3. Pearson AM et al. SPORT lumbar intervertebral disk herniation and back pain does treatment, location or morphology matter? Spine, Feb 2008;33(4):428-435.
Competing interests: None declared
Competing interests: No competing interests