SCIATICA RELATED TO HERNIATED DISC: SURGERY OR CONSERVATIVE TREATMENT



herniated-disc-sciatic

Herniated disc and sciatic


The column vertebrae are formed with 7 cervical vertebrae, 12 thoracic, 5 lumbars, 5 sacral and 3 coccygeus. Between each vertebra there is a disc formed with the annulus fibrosus and nucleus pulposus giving movement to the back, support and cushion the body´s weight.


The lower back is more prevalent to have a herniated disc having to support more weight than the other vertebrae and because it has a high mobility in flexion. The area of least resistance offered by the fibrous annulus is the posterior part. The nucleus is slightly delayed with respect to the geometric centre of the disc. This situation together with the bending movement causes the nucleus to exert more pressure on the back of the annulus.


Over the years, annulus wear down and nucleus can to go out. Usually, the herniated disc is not symptomatology but if nucleus affects the sciatic nerve we can feel symptoms. The most important symptom of sciatica is lumbosacral radicular leg pain that follows a dermatomal pattern radiating below the knee and into the foot and toes (1, 2).



lumbar-disc
Lumbar vertebrae


(Information extracted from: Jacobs, Wilco CH, et al. "Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review." European Spine Journal 20.4 (2011): 513-522)

The prevalence of sciatic symptoms reported in the literature varies considerably ranging from 1.6% in the general population to 43% in a selected working population (3). Although the prognosis is good in most patients (4), a substantial proportion (up to 30%) continues to have pain for 1 year or longer (5, 6).


 The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation.


 In total, five studies were identified. One study compared early surgery with prolonged conservative care followed by surgery if needed (7); three studies compared surgery with usual conservative care (8,9,10), and one study compared surgery with epidural injections (11).
  

Early surgery versus prolonged conservative care


 1.       Relief of leg pain was faster for patients assigned to early surgery. Intention to treat analysis
showed statistically significant more leg pain relief in favour of early surgery as compared with prolonged conservative care at 3 months. There was no significant overall difference between the two groups in disability scores during the first year. The median time to recovery was 4 weeks for early surgery and 12 weeks for prolonged conservative treatment (7).
  


Surgery versus usual conservative care

 2.       Both patient and observer ratings demonstrated that discectomy was significantly better than conservative treatment at 1 year. After 1 year, 24 of the 66 patients (36%) in the conservative care group versus 39 of the 60 patients (65%) in the surgery group reported a good outcome. No significant differences in outcomes were reported at 4 and 10 years follow-up (9).


 3.       Overall, no significant differences were found for leg pain or back pain, and subjective disability throughout the 2 years of follow up. Visual analog scale leg pain scores, however, improved more rapidly in the discectomy group first 6 weeks (8).



 4.       Confirmed disc herniation showed that both the surgery as well as the conservative treatment group improved substantially over 2 years of leg pain and/or back pain (10).
  

Surgery versus epidural steroid injections


 5.       Patients undergoing discectomy had the most rapid decrease in their symptoms. The decrease in leg pain in the discectomy group was significantly greater than in the epidural steroid injection group at 3 and 6 month follow-up intervals, but not beyond 1 year. There were no significant differences between groups for back pain throughout the follow-up (11).

 

sciatic-steroid
Epidural steroid injection



Conclusions


 In general, there is evidence that early surgery in patients with sciatica provides for a better short-term relief of leg pain as compared to prolonged conservative care. But no significant differences were found between surgery and usual conservative care in any of the clinical outcomes after 1 and 2 years.

  

Bibliography



 1. Valat JP, Genevay S, Marty M, Rozenberg S, Koes B (2010) Sciatica. Best Pract Res Clin Rheumatol 24:241–252

 2. van Tulder M, Peul W, Koes B (2010) Sciatica: what the rheumatologist needs to know. Nat Rev Rheumatol 6:139–145


 3. Konstantinou K, Dunn KM (2008) Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976) 33:2464–2472


 4. Legrand E, Bouvard B, Audran M, Fournier D, Valat JP (2007) Sciatica from disk herniation: medical treatment or surgery? Joint Bone Spine 74:530–535


 5. Vroomen PC, de Krom MC, Slofstra PD, Knottnerus JA (2000) Conservative treatment of sciatica: a systematic review. J Spinal Disord 13:463–469


 6. Weber H, Holme I, Amlie E (1993) The natural course of acute sciatica with nerve root symptoms in a double-blind placebocontrolled trial evaluating the effect of piroxicam. Spine (Phila Pa 1976) 18:1433–1438


 7. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW (2007) Surgery 
versus prolonged conservative treatment for sciatica. N Engl J Med 356:2245–2256

 8. Osterman H, Seitsalo S, Karppinen J, Malmivaara A (2006) Effectiveness of microdiscectomy for lumbar disc herniation: amrandomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976) 31:2409–2414

 9. Weber H (1983) Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 8:131–140


 10. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA 
(2006) Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296:2441–2450

 11. Buttermann GR (2004) Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am 86-A:670–679

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