Sciatica from disk herniation: Medical treatment or surgery?

Rheumatology Department, Teaching Hospital CHU Angers, rue Larrey, 49933 Angers, France.
Joint, bone, spine: revue du rhumatisme (Impact Factor: 2.9). 01/2008; 74(6):530-5. DOI: 10.1016/j.jbspin.2007.07.004
Source: PubMed


Disk-related sciatica is a common disorder that resolves without surgery in 95% of patients within 1 to 12months. Several treatment strategies designed to hasten recovery, enable a return to previous social and occupational activities, and prevent chronicization have been evaluated. Available efficacy data support the use of analgesics, nonsteroidal anti-inflammatory drugs, and epidural steroid injections, which probably relieve the pain and improve the quality of life without radically changing the midterm outcome. After a specialized evaluation of physical, psychological, social, and occupational factors, surgery may be offered to patients with persistent nerve root pain (as opposed to low back pain). The complication rate ranges from 1% to 3%. Surgery is clearly effective, shortening the time to recovery by about 50% compared to nonsurgical treatment. Whether one specific surgical procedure is better than others remains unclear. Methodological weaknesses of studies evaluating the efficacy of percutaneous methods preclude definitive conclusions. Bed rest, systemic glucocorticoid therapy, spinal manipulation, bracing, spinal traction, and physical therapy have no proven effects on the outcome of sciatica.

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    • "La revue de la littérature médicale fait apparaıˆtre que l'e ´volution douloureuse des sciatiques est la même a ` long terme (cinq ans), que les patients aient bénéficiés ou non d'un traitement. L'objectif des traitements peut ainsi e ˆtre limité a ` l'amélioration de l'ensemble des symptômes a ` court et a ` moyen terme et a ` réduire les incapacités fonctionnelles a ` moyen et a ` long terme [29] [30]. Il s'agit d'un objectif en réalité ambitieux car il est de nature a ` e ´viter la désinsertion professionnelle des patients, liée aux limitations d'activité induites par des périodes douloureuses trop longues. "
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    ABSTRACT: Objectives: Sciatica is a common disease; between 13% and 40% of the general population will experience at least one episode of sciatica due to spinal disc herniation and nerve root irritation. In some specialist centres, percutaneous intradiscal techniques can be applied as an intermediate measure between conservative treatment and surgery, with a view to avoiding the adverse events associated with surgical discectomy. Discogel(®) is a percutaneously implanted medical device for the treatment of lumbar sciatica due to a herniated disc. We performed an open, prospective, observational study in order to (a) determine whether the prior use of air disc manometry could limit the risk of nerve root irritation reportedly associated with nucleolysis and administration of Discogel(®) and (b) investigate the technique's efficacy and safety. Method: A total of 79 Discogel(®)-treated patients were systematically reviewed. A nurse anaesthetist evaluated each patient's pain levels during the procedure itself. The therapist assessed the patient on inclusion and 8weeks after the Discogel(®) procedure. A third assessment was based on a telephone interview (by an independent assessor) at least 4months after the procedure. Results: Pain levels immediately after the Discogel(®) procedure (1.7±2.0) were markedly lower than before the procedure (5.5±2.3). There were no complications. Two months after Discogel(®) administration, the initial pain level had fallen by an average of 74±34%. The outcome was quite stable over time (mean follow-up: 8months). At the end of the follow-up period, 60.7% of the patients were free of pain, 76% considered the treatment outcome to be good or very good, 74% had returned to work and 76% would recommend the treatment to a friend. Conclusion: The favourable outcomes associated with the procedure should now be confirmed in a controlled trial.
    Full-text · Article · Feb 2013 · Annals of physical and rehabilitation medicine
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    • "However, consensus is lacking as to whether surgery is useful or not in the absence of serious neurologic deficits. There seems to be consensus that surgery is indicated in carefully selected patients with sciatica and presence of a herniated lumbar disc [21, 23, 34]. In most Western countries, especially in the United States, rates of spine surgery are high [14]. "
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    ABSTRACT: Disc herniation with sciatica accounts for five percent of low-back disorders but is one of the most common reasons for spine surgery. The goal of this study was to update the Cochrane review on the effect of surgical techniques for sciatica due to disc herniation, which was last updated in 2007. In April 2011, we conducted a comprehensive search in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDRO, ICL, and trial registries. We also checked the reference lists and citation tracking results of each retrieved article. Only randomized controlled trials (RCT) of the surgical management of sciatica due to disc herniation were included. Comparisons including chemonucleolysis and prevention of scar tissue or comparisons against conservative treatment were excluded. Two review authors independently selected studies, assessed risk of bias of the studies and extracted data. Quality of evidence was graded according to the GRADE approach. Seven studies from the original Cochrane review were included and nine additional studies were found. In total, 16 studies were included, of which four had a low risk of bias. Studies showed that microscopic discectomy results in a significantly, but not clinically relevant longer operation time of 12 min (95 % CI 2-22) and shorter incision of 24 mm (95 % CI 7-40) compared with open discectomy, but did not find any clinically relevant superiority of either technique on clinical results. There were conflicting results regarding the comparison of tubular discectomy versus microscopic discectomy for back pain and surgical duration. Due to the limited amount and quality of evidence, no firm conclusions on effectiveness of the current surgical techniques being open discectomy, microscopic discectomy, and tubular discectomy compared with each other can be drawn. Those differences in leg or back pain scores, operation time, and incision length that were found are clinically insignificant. Large, high-quality studies are needed, which examine not only effectiveness but cost-effectiveness as well.
    Full-text · Article · Jul 2012 · European Spine Journal
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    • "The role of antidepressant drugs in chronic low back pain remains unclear and is not strongly supported by the literature [76]. Although, anti-depressants have no effect on radicular pain, they may help alleviate LBP [5]. "
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    ABSTRACT: Acute low back pain (LBP) with associated sciatica is a common problem leading patients to see a physician. It is usually a benign and self-limited disorder. Radicular pain in the distribution of the sciatic nerve, resulting from herniation of one or more lumbar intervertebral discs, is a common and painful event. The lifetime incidence of this situation is expected to be between 13% and 40%. Compression of a lumbar nerve root by a herniated intervertebral disc is a common cause of sciatica. Non-discogenic causes of sciatica include benign and malignant tumors, infections including epidural abscess and discitis, vascular compression, bony compression due to spinal stenosis, epidural adhesions, Piriformis syndrome, or compression by gynecological structures (i.e. uterine fibroid, pelvic endometriosis).The evidence suggests that a multifactorial interaction of inflammatory, immunological, and pressure-related processes may play a role in the pathophysiology of sciatica neuralgia. Sciatica is a clinical diagnosis. The history and physical examination can frequently reveal the etiology..Imaging studies including MRI or CT myelograms may help with the diagnosis and in selecting specific treatment plans. Several conservative and surgical therapeutic options are available for management of discogenic sciatica. Physical therapy, activity modification, nonsteroidal anti-inflammatory drugs and analgesics are the most commonly prescribed treatment. While commonly used, physical therapy, epidural steroid injections, systemic glucocorticoid therapy, trigger point injectionsspinal manipulation, bracing, and traction have little support in the literature. Different types of electro-acupuncture stimulation have had mixed results in sciatica patients. Further clinical trials are necessary to confirm their efficacy. Chemonucleolysis is the last step of conservative management in patients without extruded disk material. Allergic reactions are a possible severe complication and plans should be in place to deal with any reaction that might occur. There is limited scientific data supporting this treatment. This procedure does not affect the outcome of the later surgery if necessary. Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc herniations that fail to resolve with the conservative management or in patients with severe paralysis or a cauda equina syndrome. To prevent complications, an appropriate pre-operative work up including neuroimaging is necessary, especially when there is a lack of correlation between the history, physical examination, or radiologic examination. Surgery has been shown to be highly effective, shortening the time to recovery by about 50% compared to nonsurgical treatment. Whether one specific surgical procedure is better than others remains uncertain. Methodological limitations of studies evaluating the efficacy of percutaneous methods prevent ultimate conclusions. Post-operative complications occur in 1% to 3% of cases. If patients were appropriately selected, failures happen in less than 10% of cases, which are primarily due to recurrent disc herniation or fibrosis. After pain is controlled, a multidisciplinary approach including physical, psychological, socioeconomic, and self-management techniques is recommended.
    Full-text · Article · Apr 2011
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