Studies: Surgery No Better for Sciatica

Our Review Summary

This story reports on the publication of results from a large trial in the Journal of the American Medical Association evaluating surgery compared to non-operative care for the treatment of sciatica. This trial represented the first randomized trial of surgery for herniated disc in the US since 1983 and significantly improved our knowledge of the benefits of surgery. There are several key points from this study that are important for people with herniated disc to understand:

1. Regardless of the treatment selected, surgical or non-operative care, most people in the study got better after two years.

2. Patient preferences for treatment choices, the bothersomeness of symptoms, and whether they can afford to take some extra time to get better, should underlie the treatment decision. This means that patients need to be a part of the decision process and should not simply look to their doctor for the answer.

3. In the study, there were no negative consequences from waiting to have surgery. There were no cases of permanent nerve damage from waiting and the high rate of crossing from one treatment group to another suggests that patients can change their mind after making an initial treatment decision without worrying that they'll never get better. This means that patients shouldn't feel pressured to make a fast decision.

4. All patients need a lot more help making the decision that is right for them. Every patient in the study watched a video that provided the key facts a patient needs to make a good decision and help them weigh what matters most to them.

This story does an excellent job of describing the recent results, including the strengths and limitations of the available evidence.

By accurately describing the seriousness and prevalence of sciatica and herniated disc, the story does not engage in disease mongering. It is important to distinguish patients with sciatica due to a herniated lumbar disc who were evaluated in this study from patients with low back pain without sciatica. One cannot generalize the results of treatment for sciatica to low back pain alone.The story describes how non-operative care can be just as effective as surgery and mentions specific non-operative options such as physical therapy and painkillers.

The story adequately describes the details of the design of the current studies and points out the controversy over the large numbers of cross-overs ("Many patients didn't stay in their assigned group: Almost half those assigned to noninvasive treatment ultimately had surgery, and more than one-third of those assigned to surgery ended up choosing less invasive treatment instead."). The story provides quantification of benefits from the observational arm of the study only. The story should have provided the same numbers from the randomized arm, however the story adequately addresses the overall findings and their importance. The story also mentions that four percent of patients required another operation and that no one developed cauda equina syndrome (Cauda equina syndrome occurs when the nerve roots are compressed and paralyzed, cutting off sensation and movement. Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage.)

Because the story quotes three experts, the reader can assume that the story did not rely on a press release as the sole source of information. Finally, the story does mention the cost of surgery (around $6,000), however the story should have provided costs of non-operative care by way of comparison.