BACKGROUND AND PURPOSE:

• Treatment for sciatica starts with non-surgical intervention, and can progress to surgical intervention if pain persists
• However, evidence supporting use of surgery in treating sciatica is limited
• Liu et al. (BMJ, 2023) investigated the effectiveness and safety of surgery compared with non-surgical treatment for sciatica

METHODS:

• Systematic review and meta-analysis
• Study inclusion criteria
  • Randomized controlled trials
  • Studies that compared any surgical treatment with non-surgical treatment, epidural steroid injections, or placebo or sham surgery
  • Studies in people with sciatica of any duration due to lumbar disc herniation diagnosed by radiological imaging
• Study design
  • Data were pooled using a random effects model
  • Risk of bias was assessed with the Cochrane tool | Certainty of evidence was assessed with GRADE criteria
  • Follow up was intermediate term (≤6 weeks) | Short term (>6 weeks and ≤3 months) | Medium term (>3 and <12 months) | Long term (at 12 months)
  • Pain and disability scores: 100 point scale ranging from 0 (no pain or disability) to 100 (worst pain or disability)
• Primary outcomes
  • Leg pain
  • Disability
• Secondary outcomes
  • Adverse events | Back pain | Quality of life | Satisfaction with treatment

RESULTS:

• 24 trials
  • 12 studies (1711 participants) investigated the effectiveness of discectomy compared with non-surgical treatment or epidural steroid injections
• Very low to low certainty evidence showed that discectomy, compared with non-surgical treatment, reduced leg pain
  • Immediate term: mean difference −12.1 (95% CI, −23.6 to −0.5)
  • Short term: MD −11.7 (95% CI, −18.6 to −4.7))
  • Medium term: MD −6.5 (95% CI, −11.0 to −2.1)
• Negligible effects of discectomy on leg pain were found at long term
  • Long term: MD −2.3 (95% CI, −4.5 to −0.2)
• For disability, small, negligible, or no effects were found
• A similar effect on leg pain was found when comparing discectomy with epidural steroid injections
• For disability, compared to epidural steroid injections, discectomy had
  • A moderate effect was found at short term
  • No effect was observed at medium and long term
• The risk of any adverse events was similar between discectomy and non-surgical treatment
  • RR 1.34 (95% CI, 0.91 to 1.98)

CONCLUSION:

• There is low to very low certainty evidence that discectomy can improve leg pain symptoms in individuals with sciatica, compared to non-surgical treatment
• However, effects waned over time and surgery had a negligible effect on leg pain long term
• The authors state

Discectomy might be an option for people who require rapid leg pain relief and disability improvement, when the benefits outweigh the risks and costs related to surgery

Learn More – Primary Sources:

Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials