Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

doi:10.1136/bmj.a143

BMJ 2008;336:1355-1358 (14 June), doi:10.1136/bmj.a143 (published 23 May 2008)

Research

Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

Wilco C Peul, neurosurgeon, epidemiologist¹^,2, Wilbert B van den Hout, health economist³, Ronald Brand, statistician⁴, Ralph T W M Thomeer, head of department¹, Bart W Koes, head of department⁵, for the Leiden-The Hague Spine Intervention Prognostic Study Group

¹ Department of Neurosurgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands, ² Department of Neurosurgery, Medical Centre Haaglanden, The Hague, Netherlands, ³ Department of Medical Decision Making, Leiden University Medical Centre, ⁴ Department of Medical Statistics, Leiden University Medical Centre, ⁵ Research Department of General Practice, Erasmus Medical Centre, 3000 CA Rotterdam, the Netherlands

Correspondence to: W C Peul w.c.peul{at}lumc.nl

Objectives To evaluate the effects of early lumbar disc surgerycompared with prolonged conservative care for patients withsciatica over two years of follow-up.

Design Randomised controlled trial.

Setting Nine Dutch hospitals.

Participants 283 patients with 6-12 weeks of sciatica.

Interventions Early surgery or an intended six months of continuedconservative treatment, with delayed surgery if needed.

Main outcome measures Scores from Roland disability questionnairefor sciatica, visual analogue scale for leg pain, and Likertself rating scale of global perceived recovery.

Results Of the 141 patients assigned to undergo early surgery,125 (89%) underwent microdiscectomy. Of the 142 patients assignedto conservative treatment, 62 (44%) eventually required surgery,seven doing so in the second year of follow-up. There was nosignificant overall difference between treatment arms in disabilityscores during the first two years (P=0.25). Improvement in legpain was faster for patients randomised to early surgery, witha significant difference between "areas under the curves" overtwo years (P=0.05). This short term benefit of early surgerywas no longer significant by six months and continued to narrowbetween six months and 24 months. Patient satisfaction decreasedslightly between one and two years for both groups. At two years20% of all patients reported an unsatisfactory outcome.

Conclusions Early surgery achieved more rapid relief of sciaticathan conservative care, but outcomes were similar by one yearand these did not change during the second year.

Trial Registry ISRCT No 26872154.

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Rapid Responses:

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