Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj-2022-070730 (Published 19 April 2023) Cite this as: BMJ 2023;381:e070730Linked Editorial
Early surgery for sciatica
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Dear Editor
Sciatica is one of the most frequently reported complaints; it affects quality of life and reduces social and economic efficacy. Sciatica that is caused by acute herniation of a lumbar disk is expected to improve with conservative care in 90% of patients within 4 months after the onset of symptoms. Percutaneous endoscopic transforaminal discectomy (PETD), which is a percutaneous endoscopic lumbar discectomy (PELD), has become a routinely performed minimally invasive spinal procedure for the treatment of lumbar disc herniation (LDH) (1,2). However, with the advancements in surgical methods, optical designs, and surgical instruments, PETD has become the treatment option for lumbar spinal stenosis (LSS) in recent years (3,4). PETD can not only remove disc herniation but also hyperplastic facet joints, hypertrophic ligamentum flavum, and osteophytes, which can increase the scale of the foramen, lateral recess, and even the central canal. In a recent study, PETD showed clinical outcomes comparable to the conventional open decompression and fusion surgery, with advantages of lesser tissue trauma, faster rehabilitation, and lower intra-operative blood loss, risk of degeneration of adjacent segments and cost of postoperative care (5,6). A recent analysis reflects lot of ambiguity in efficacy of discectomy and conservative methods. (7)
Chang et al have conducted a systematic review and a meta-analysis which compares surgical treatment with non surgical treatment, epidural steroid injections, placebo or sham surgery whereas other conservative therapy methods applied in many developing countries with limited resources have not been included.
Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. (8)
In alternative medicine very unusual local therapies without any scientific evidence like stabbing the leg or back have been used for the treatment of Sciatica. (9). A number of systematic reviews have appeared for various treatment modules for sciatica, but none of them presents conclusive high quality evidence for efficacy of any single procedure or a procedure in combination ( 10, 11,12).
The absence of conclusive directions for efficacy of any treatment module for sciatica calls for attention of policy advisors, health administrators, neurosurgeons, neurologists, orthopedicians, anesthetists, acupuncturists, physiotherapists, traditional healers and other representatives from potent health service providers to sit together to chalk out new assessment criteria and clinical algorithms for better defining the efficacy of a particular treatment module.
1. Pan M, Li Q, Li S, Mao H, Meng B, Zhou F, Yang H. Percutaneous endoscopic lumbar discectomy: indications and complications. Pain physician. 2020; 23(1):49.
2. Tacconi L, Baldo S, Merci G, Serra G. Transforaminal percutaneous endoscopic lumbar discectomy: outcome and complications in 270 cases. Journal of neurosurgical sciences. 2020; 64(6):531-6.
3. Wu B, Tian X, Shi C, Jiang C, Zhang J, Zhan G, Xie D. Clinical outcomes of “U” route transforaminal percutaneous endoscopic lumbar discectomy in chronic pain patients with lumbar spinal stenosis combined with disc herniation. Pain Research and Management. 2021; 2021.
4. Song QP, Hai B, Zhao WK, Huang X, Liu KX, Zhu B, Liu XG. Full‐Endoscopic Foraminotomy with a Novel Large Endoscopic Trephine for Severe Degenerative Lumbar Foraminal Stenosis at L5S1 Level: An Advanced Surgical Technique. Orthopaedic Surgery. 2021; 13(2):659-68.
5. Song Q, Zhu B, Zhao W, Liang C, Hai B, Liu X. Full-endoscopic lumbar decompression versus open decompression and fusion surgery for the lumbar spinal stenosis: a 3-year follow-up study. Journal of Pain Research. 2021:1331-8.
6. Wei FL, Zhou CP, Liu R, Zhu KL, Du MR, Gao HR, Wu SD, Sun LL, Yan XD, Liu Y, Qian JX. Management for lumbar spinal stenosis: a network meta-analysis and systematic review. International Journal of Surgery. 2021;85:19-28.
7. Bailey CS, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, Rosedale R, Bailey SI, Gurr KR, Siddiqi F, Glennie A. Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. New England Journal of Medicine. 2020;382(12):1093-102.
8. Ter Meulen B, Overweg C, Feenstra T, Brouwer B, Terheggen M, van Dongen H, Kallewaard JW, Ostelo R, Weinstein H. Diagnosis and treatment of sciatica in the Netherlands: a survey among neurologists and Anesthesiologists. European Neurology. 2021; 84(4):219-29.
9. Khan B, Alam I, Haqqani U, Ullah S, Hamayun S, Khanzada K, Bibi Z. Unusual Local Therapies Used for the Treatment of Low Back Pain and Sciatica: Concepts and Approaches. Cureus. 2021; 13(8).
10. Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. European Spine Journal. 2011; 20:513-22.
11. Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The efficacy of acupuncture for the treatment of sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2015; 2015.
12. Bachmann J, Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Deutsche Zeitschrift für Akupunktur. 2016; 59(3):29-30.
Competing interests: No competing interests
Re: Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials
Dear Editor,
We read with interest the recent systematic review and meta-analysis from Liu and colleagues published in the BMJ.4 Although the authors are to be congratulated for collating the data from such a large number of patients in a commonly encountered pathology, we are of the view that their conclusions are not supported by data provided by high quality randomized controlled trials (RCT) and may represent an over-reliance on the pooled results of studies of variable quality.3
In particular, we wish to comment on the absence of a recommendation to consider transforaminal epidural steroid injection (TFESI) as an alternative to early surgery or continued conservative management. The NERVES trial was a multi-centre RCT of microdiscectomy vs. TFESI in the management of sciatica due to a herniated lumbar disc published by our group.5 This trial demonstrated no difference in relief of back and leg pain when surgery and the less invasive TFESI were compared, and the majority of patients randomised to the TFESI arm did not require surgical intervention during the follow-up period. Furthermore, all of the treatment associated serious adverse effects were observed in the surgical arm. We found it curious, therefore, that the authors did not advocate for the use of TFESI as an early intervention for this pathology in view of the demonstrable evidence of efficacy. More broadly, the majority of studies included in this systematic review and meta-analysis were found to be at high or unknown risk of bias (Supplemental Table 11) and therefore pooling their results with a view to making definitive treatment recommendations is problematic.
Moreover, the assertion from the authors that “No trials reported outcomes for quality of life and treatment satisfaction.” is incorrect; NERVES reported patient satisfaction outcomes for treatment satisfaction using a previously validated Likert scale and quality of life was assessed using the widely applied EuroQol -5D-3L questionnaire.1,2,5
In summary, research from our group has demonstrated that the use of TFESI in patients with sciatica of 6 weeks-12 months duration was an effective intervention that obviated the requirement for surgical intervention in ~60% of those patients that received it.5 We strongly recommend that this intervention be considered as an initial alternative to surgery in patients with symptomatic posterolateral disc herniations without significant associated neurological deficits. Finally, the use of meta-analyses of poorly performed studies to draw conclusions on optimal treatment modalities when well-designed RCTs addressing the question are available is not an approach we consider to be advisable.
References:
1. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy 16:199-208, 1990
2. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, et al: Outcome measures for low back pain research. A proposal for standardized use. Spine (Phila Pa 1976) 23:2003-2013, 1998
3. Jensen RK, Kongsted A, Kjaer P, Koes B: Diagnosis and treatment of sciatica. Bmj 367:l6273, 2019
4. Liu C, Ferreira GE, Abdel Shaheed C, Chen Q, Harris IA, Bailey CS, et al: Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ 381:e070730, 2023
5. Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, et al: Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluation. Lancet Rheumatol 3:e347-e356, 2021
Competing interests: No competing interests