From Pages to Practice

By Krista Nottage, MBBS

Published May 6, 2020


Sciatica is so common that we all know at least one patient who has described the sharp, shocking, shooting pain. Sciatica accounts for thousands of hospital and clinic visits each year and countless consultations, prescriptions, and quality-of-life adjustments. As the largest nerve in the body, the sciatic nerve is a powerhouse for locomotion. Lumbar disc herniation that leads to unilateral impingement of this nerve causes a pain syndrome that’s a true “pain in the butt.”

More often than not, the pain resolves with conservative care within a few months of symptom onset. When pain persists, treatment options are still evolving. Typically, surgical interventions have been a last resort. Now, new evidence suggests that surgery is a true and lasting option for relief.

In a trial published in NEJM, patients with chronic (4−12 months duration) unilateral leg pain caused by nerve-root compression at the L4–L5 or L5–S1 levels were randomized to receive either microdiskectomy or conservative care. After one year of follow-up, surgery came out on top. Patients who received microdiskectomy reported less leg and back pain and greater patient satisfaction than patients who received conservative care.

The following NEJM Journal Watch summary explains the study in more detail.


Diskectomy vs. Conservative Care for Sciatica

Allan S. Brett, MD reviewing Bailey CS et al. N Engl J Med 2020 Mar 19

In the few large trials in which researchers have compared surgical and nonsurgical management of sciatica caused by disk herniation, most participants had symptoms for less than 3 months. In those studies, pain relief at 1 year was similar in surgical and nonsurgical groups. In this new randomized trial from a single Canadian center, 128 patients with longer-duration sciatica (4–12 months) underwent either microdiskectomy or conservative care (consisting of physical therapy, plus epidural steroid injections in some cases). All patients had nerve-root compression at the L4–L5 or L5–S1 level on magnetic resonance imaging, and none had epidural injections or physical therapy prior to enrollment. Microdiskectomies were performed by a fellowship-trained spine surgeon.

At baseline, mean scores for leg pain were ≈8.0 (on a 10-point scale) in both groups. At 6 months, mean pain scores were significantly lower in the surgery group than in the conservative-care group (mean decrease, 4.9 vs. 2.8 points). Pain outcomes remained better with surgery than with conservative care at 1 year; improvement in disability scores also favored surgery. Seven of 64 patients randomized to surgery ultimately did not undergo it; 22 of 64 patients randomized to conservative care ultimately crossed over to surgery (at an average of 11 months after enrollment).

Comment: This study strengthens the case for microdiskectomy in selected patients with documented nerve-root compression and persistent sciatic pain of moderate duration (4–12 months). However, patient preferences still should drive the decision, and initial conservative management remains a valid option for patients who wish to avoid surgery.

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Krista is a 2019-2020 editorial fellow at the New England Journal of Medicine. She is from Nassau, Bahamas where she is training in general surgery at the University of the West Indies.