• To assess the relative benefits of surgical and nonsurgical treatment over a 10 year period using a broad range of validated patient-reported outcome measures.

The debate of surgical management vs. nonsurgical care for the treatment of sciatica resulting from a lumbar disc herniation remains ongoing. This study by Atlas et al (2005) represents a long term prospective investigation looking at the outcomes of surgery vs. conservative treatment up to ten years for patients with sciatica due to a disc herniation. Up until this study was published, only one study (Henrik) in 1983 provided the primary evidence of surgery vs. nonsurgical treatment for sciatica over a ten year period.

Five hundred and seven patients were initially enrolled in this current study which was part of the Maine Lumbar Spine Study. Outcomes after 1 and 5 years had already been published. Outcome measures were based on back and leg pain scores, bothersome index, Modified Roland Scale, and SF36. Based on the authors presented data of baseline characteristics, there were differences in statistically significant differences in Worker’s Comp status, positive straight leg raise findings, abnormal examination findings, and differences in SF36 domains of physical function, bodily pain, and general health. Despite “almost all patients” in the surgical cohort had an open discectomy, other operative approaches including percutaneous discectomy were utilized, which may have differing outcomes in both the short and long terms.  Furthermore, there was some crossover for those who initially chose nonsurgical care into the surgical group prior to the first follow-up evaluation at 3 months (N=38).

The results of the study showed that surgically treated patients had better functional status and were more satisfied at 10 years. However, as noted by the authors, these findings did not translate into better disability and work outcomes on a long term basis.  Of concern is the fact that among those who initially underwent surgery, 25% had at least one additional spine surgery over the course of the 10 years . By comparison, the reoperation rate in the SPORT trial was 15% (up to 8 years).   Interestingly, the outcomes of further surgery for these patients was poor.  The authors due admit that it is unknown if the differences seen between the two groups was entirely due to surgery or if there was a confounding variable involved.

Since this study was published, additional investigations looking at surgical vs nonoperative treatment have identified mixed outcomes. Kerr et al (2015) looked at outcomes of operative and nonoperative treatment at 8 years for patients enrolled in the Spine Patient Outcomes Research Trial (SPORT).   Using the intent-to-treat analysis, the authors concluded that there were no significant differences between surgical and nonoperative treatments based on SF36 and ODI scores. The as-treated analysis showed an advantage for surgically treated patients, however, there is concern for potential bias and confounding. Lurie et al. (2014) looked at outcomes using data from the SPORT trial and concluded that carefully selected patients who underwent surgery achieved greater improvement and nonsurgical patients up to 8 years.

A majority of the data shows that despite a more rapid decrease in pain levels seen in the patients who undergo surgery, there does not appear to be any significant differences seen long term (10 years). It should also be noted that while surgery is effective, varying percentages of patients continue to experience mild to moderate sciatica long-term, based on published data (Machado et al. 2016). 

This study provides a great basis for future investigations looking at surgical vs. nonoperative treatment of sciatica including  a deeper analysis of potential prognostic factors such as timing of surgery and type of  approach.