Outcomes/Effectivness Research

Patients with sciatica and lumbar disc herniation or spinal stenosis treated surgically or medically have similar 10-year outcomes

Sciatica, radiating pain in the lower back and legs, is generally caused by a herniated lumbar disc or lumbar spinal stenosis (mid-life degenerative changes in the spine). Both these conditions can be treated with nonsurgical approaches or surgery. Three lumbar spine studies supported by the Agency for Healthcare Research and Quality (HS08194 and HS09804) found similar 10-year outcomes of sciatica patients initially treated with surgery or with nonsurgical methods. They are described here.

Atlas, S.J., Keller, R.B., Wu, Y.A., and others (April 2005). "Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study." Spine 30, pp. 927-935.

This study found similar 10-year outcomes among 217 patients with sciatica who had herniated lumbar discs initially treated with surgery and 183 similar patients initially treated with nonsurgical methods. A herniated lumbar disc can put pressure on the sciatic nerve that runs from the lower back down the back of each leg. The result can be debilitating lower back and leg pain, and perhaps numbness, burning or tingling in the legs or feet, a condition called sciatica. Surgery (discectomy) is generally reserved for patients who don't respond to conservative treatment such as medications, physical therapy, or manipulation.

Over a 10-year period, the investigators compared several outcomes of patients initially treated with surgery or nonsurgery. By 10 years, 25 percent of surgical patients had undergone at least one additional lumbar spine operation, and 25 percent of nonsurgical patients had at least one lumbar spine operation.

At 10 years, more surgical than nonsurgical patients reported that their low back and leg pain were much better or completely gone (56 vs. 40 percent) and were more satisfied with their current status (71 vs. 56 percent). Yet, a similar proportion of both groups reported improvement in their predominant symptoms of back or leg pain (69 vs. 61 percent) and disability status.

Atlas, S.J., Keller, R.B., Wu, Y.A., and others (April 2005). "Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine lumbar spine study." Spine 30(8), pp. 936-943.

Surgery rates for spinal stenosis have dramatically increased in the U.S. Medicare population. This study of 97 spinal stenosis patients with sciatica—56 initially treated surgically, and 41 initially treated nonsurgically—found similar outcomes at 10 years. Outcomes at 1 and 4 years favored initial surgical treatment. However, by 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved (53 vs. 50 percent), their predominant symptom (either back or leg pain) was improved (54 vs. 42 percent), and they were satisfied with their current status (55 vs. 49 percent). At 10 years, surgical patients reported less severe leg pain and greater improvement in back-specific functional status than nonsurgically treated patients. By 10 years, 23 percent of surgical patients had undergone at least one additional lumbar spine operation, and 39 percent of nonsurgical patients had at least one lumbar spine operation. Patients who underwent subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Thus, outcomes according to actual treatment received at 10 years did not differ.

Chang, Y., Singer, D.E., Wu, Y.A., and others (May 2005). "The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years." Journal of the American Geriatric Society 53, pp. 785-792.

This study included the 97 patients in the previous study who had 8 to 10 years of followup and 47 additional patients who completed at least one followup survey but not the 8 to 10 year survey. Seventy-seven sciatica patients with lumbar spinal stenosis initially treated surgically and 67 patients initially treated nonsurgically also revealed similar outcomes at 10 years, as well as an overall 10-year survival rate of 69 percent. The researchers used models to analyze the longitudinal data over the 10-year period. The models included initial treatment, time period, interaction between treatment and time, baseline health score, patient age and sex, and time-varying general health status score.

The 10-year rate of subsequent surgical procedures was 23 percent and 38 percent for patients initially treated surgically and nonsurgically, respectively. As in the previous two studies, patients undergoing initial surgical treatment had worse baseline symptoms and functioning than those initially treated nonsurgically. For all outcomes and at each time point, surgically treated patients reported greater improvement in symptoms and functional status and higher satisfaction than nonsurgically treated patients. However, the relative benefit of surgery diminished over time, so that the differences for low back pain and satisfaction were no longer significant between 5 and 10 years.

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