Do the results of this study apply to all patients with sciatica related to a disc herniation? The patients excluded from the study would suggest no. Individuals with cauda equina syndrome or severe muscle weakness were excluded because of the need for immediate surgical decompression. Patients who had a prior disc herniation, prior spine surgery, pregnancy, or severe coexisting disease were not eligible. Therefore, this study applies to young, healthy individuals with sciatica associated with their first disc herniation.
Another of my concerns is the absence of a standardized approach to medical therapy. The conservative treatment subjects were prescribed activities as tolerated, pain medications, and physiotherapy visits in any combination. The absence of guidelines for medical therapy remains a major failing of studies designed by spine surgeons.2 Of interest, the surgical technique for discectomy is described in greater detail. My point is that conservative medical therapy outcomes could be better than what is described in this paper.
Overall, patients with sciatica from a herniated disc should be encouraged by this study. At the end of a year, they should experience minimal disability and have residual pain of 1 or less on a visual analogue pain scale (VAS) independent of their choice of therapy. Surgery can be delayed for months and can still offer rapid relief of symptoms for those with persistent intractable pain who do not resolve in the usual time course.
References
- Postachinni F. Results of surgery compared with conservative management for lumbar disc herniations. Spine. 1996;1383-1387.
- Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006;296:2451-2459.
