Surgical versus non-surgical treatment efficacy inconclusive - need to view Sciatica through lens of a surgeon, neurologist and anesthetist
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
21 April 2023
Dr. Cherry Bansal
MBBS,MHA (MD), Junior Resident
Dr. Suresh Goyal, MS, M.Ch., Dr. Ushav Bansal, MBBS, Dr. Parveen Bansal, Ph.D. D.Pharm. FAMS., Dr. Shifali Gupta, MD,(DM), Dr. Renu Bansal, Ph.D., Dr. Vikas Gupta, M.Pharm. Ph.D.
Department of General Medicine, Himalayan Institute of Medical Sciences, Jolygrant, Uttrakhand, India.
University Center of Excellence in Research, Academic Block, Baba Farid University of Health Sciences, Faridkot, Punjab, India.
Rapid Response:
Surgical versus non-surgical treatment efficacy inconclusive - need to view Sciatica through lens of a surgeon, neurologist and anesthetist
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