Schmid and colleagues have debated this issue again in the BMJ this month.
International guidelines for sciatica recommend a stepped care approach starting with conservative management (ie, physiotherapy and medication), escalating to steroid injections, then surgery when non-surgical treatment has failed or when major radicular weakness is present. Unfortunately, evidence on the effectiveness of both non-surgical and surgical options is uncertain.
MRI of Prolapsed disc
In a linked paper, Liu and colleagues reported a systematic review and meta-analysis of 24 randomised clinical trials evaluating the evidence of surgical care for people with sciatica due to lumbar disc herniation. Their meta-analysis suggests that discectomy is statistically significantly superior to non-surgical treatment in reducing leg pain and disability. However, effects were moderate at best (10-20 point reduction on a 100 point scale), but mostly small (5-10 point reduction). The benefits of discectomy were only evident in the short to medium term, with no clinically meaningful effects beyond 12 months.
Despite limitations related to the low certainty of evidence, Liu and colleagues’ review raises an important point for clinicians, people with sciatica, and policy makers. Growing evidence for worse surgical outcomes associated with prolonged symptom duration, together with the better short and medium term benefits of discectomy reported in this systematic review, challenge the stepped care approach that offers the least invasive options first to everyone with sciatica.
Perhaps rapid surgical triage would be preferable for people with discogenic sciatica and a clear indication for surgery when rapid pain relief is a priority. But, in reality, access to specialist services is difficult and delayed in many health systems globally, requiring proactiveness and perseverance from the patient. Therefore easier and faster access to surgical triage is needed for patients who are most likely to benefit.
