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Rapid Responses: Rapid Responses published:
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Early surgery for relief of sciatic pain
- Garth Robertson (26 November 2007)
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Surgery for Disc Disease
- Keith Bush (28 November 2007)
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Is Surgery really necessary for disc prolapses?
- Alasdair Jacks (28 November 2007)
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early surgery for sciatica
- Judith M Neaves (29 November 2007)
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Epidural steroids in acute sciatica
- Michael F Vagg (29 November 2007)
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Garth Robertson, Course Director (London College of Osteopathic Medicine) LCOM, 10 Boston Place, London NW1 6QH
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Alastair Gibson's editorial (1) might lead one to believe that early micro-discectomy to relieve the symptoms of acute sciatica is the treatment of choice. The New England Journal of Medicine paper(2)demonstrates that surgery is an effective way of reducing pain. The conservative management arm of the study offered a small input of physiotherapy and oral medication for pain relief. It did not include a trial of epidural or any manipulation. Early effective control of sciatic pain is likely to reduce the risk of long term disability, as it facilitates faster functional restoration. It certainly can not be assumed that it affects the long term natural history of the underlying disc disease. The resource and financial implications for treating acute sciatica with early MRI scan and surgery without a trial of the conservative management strategies mentioned above are huge. Graduates from The London College of Osteopathic Medicine and many members of the British Institute of Musculoskeletal medicine use a simple caudal steroid epidural technique without using local anaesthetic. In patients selected by careful clinical assessment (including some tests described by Butler called the “slump test”) early epidural injection using this method seems to afford excellent short term reduction in pain which allows effective mobilisation and return to normal activity for the patients. The technique is inexpensive and does not require a secondary care setting for its application. Before patients are referred for early surgery, I believe these "low tech'", cheap, primary care based conservative treatment methods should be evaluated by controlled trials. Garth Robertson
1 Gibson JNA. Surgery for disc disease BMJ 2007;335:949 2 Peul WC, van Houwelinger HC et al. Surgery versus prolonged conservative treatment for sciatica. NEngl J Med 2007;356:2245-56 Competing interests: None declared |
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Keith Bush, Consultant Orthopaedic & Sports Physician 6, Harley Street, London W1G 9PD
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I was particularly interested to read Alastair Gibson’s editorial (BMJ2007;335:949) which addresses a number of separate clinical syndromes. Whilst there clearly is a place for surgery in managing disc disease in selected patients, the dilemma remains on just how best to select these patients. The Back Letter 1 points out that “interpretation of the SPORT disc surgery series in medical journals is variable and contradictory”. Carragee’s editorial in JAMA 2 seems to be balanced in concluding that disc surgery has a significant early advantage over non-operative care, but that both surgical and non-operative treatments were associated with favourable long-term outcomes with differences narrowing over time and with both forms of treatment being safe. Peul 3 draws attention to the fact that the incidence of disc surgery in The Netherlands is only second to that in the USA, with Dutch guidelines advocating discectomy for sciatica which has failed to resolve in 6 weeks. They set up a randomised study with patients being offered surgery at 6 weeks or at 6 months. By six months, many of the patients did not require surgery, and again they demonstrated that the early response to surgery was more favourable than with conservative care. However, at one year, the outcomes were no different. There is nothing new about the natural history of sciatica ultimately having a satisfactory outcome. Hakelius 4 and subsequently Weber 5 drew the same conclusions too. We were able to demonstrate that 76% of large herniations or sequestrations had partly or completely regressed at a year 6. This is precisely the pathomorphology which many surgeons might select as being ideal for microdiscectomy. In other words, if patients’ pain can be satisfactorily controlled, then the reason to operate ultimately disappears. It is also important to realise that discectomy does not preclude a patient from suffering a recurrent herniation at either the same level or being selectively predisposed to further herniations of adjacent intervertebral discs. Thus, in order to avoid multiple surgeries, it would seem prudent to apply the least invasive approach initially. On the other hand, there are many pain free patients with significant disc herniations and the rationale for addressing inflammatory factors has also been well established. For instance, there were a number of papers devoted to this in Spine (Vol 19, No.1. 1984). Whilst the use of epidural steroids remains controversial, we were able to demonstrate their intermediate- term efficacy in managing sciatica 7. We subsequently used serial epidural steroid injections to control patients’ pain whilst their herniations regressed naturally 6 . Thus, the evidence base suggests that there is nothing to be lost in offering patients suffering from sciatica an adequate trial of conservative measures including serial image guided epidural steroid injections. If they fail to make satisfactory progress and if the pathomorphology fails to regress over time, then they should be selected for surgical microdiscectomy. On the other hand, in the very few cases of progressive polyradicular neurological deficit, including complete foot drop and cauda equina syndrome, most authorities would agree that early surgical decompression offers the best chance of full neurological recovery. With kind regards Yours sincerely Dr Keith Bush MB BS MD(Lond) FFSEM(UK)
References: 1. The Back Letter October 2007 Vol.22, No. 10, 112-113 2. Carragee E, Surgical treatment of lumbar disc disorders, JAMA, 2006;20:2485-7 3. Peul WC et al. Surgery versus prolonged conservative treatment for sciatica. New England J Med, 2007; 356: 2245-56 4. Hakelius A: Prognosis in sciatica. Acta Orthop Scand (Suppl) 1970 129:1-76, 5. Weber H: Lumbar disc herniation: A controlled prospective study with ten years of observation. Spine 81983 (2): 131-140, 6. Bush K and Hillier S. A Controlled Study of Caudal Epidural Injections of Triamcinolone Plus Procaine for the Management of Intractable Sciatica. Spine, 1991 Vol. 16· No. 5, May 572-575 7. Bush K. et al. The Natural History of Sciatica Associated with Disc Pathology: A Prospective Study with Clinical and Independent Radiologic Follow-Up, SPINE, October 1992 Vol.17 · No. 10 1205-1212 Competing interests: None declared |
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Alasdair Jacks, Musculoskeletal Physician Monmouthshire Local Health Board
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The editorial in BMJ 10 November leaves the distinct impression that most patients would benefit from a surgical solution to their acute lumbar disc prolapse (1). There are several misleading statements in this editorial however. After quoting the recent Cochrane review which he co-authored (2) Gibson implies in quoting Peul (3) that surgery is offered at a mean of 2.2 weeks versus a mean of 18.7 weeks ‘after prolonged conservative treatment’. This is misleading on two counts firstly Peul does not enrol patients to the trial until they had a minimum of six weeks of symptoms hence early surgery is at minimum of mean 8.2 weeks. Secondly, the prolonged conservative treatment was suboptimal. It consisted of usual GP care, information about the benign prognosis and likely resolution, optimizing analgesia and physiotherapy only if these were not helping. Butterman in a paper quoted in the editorial (4) found that although steroid epidurals at six weeks were less effective than surgery, nevertheless they provided effective pain relief in 50% of patients for up to 3 years. Similarly the SPORT trial (5) had such a high crossover rate –surgery was not done in 50% of those assigned to it, while 1/3 of the conservative arm had surgery eventually –that there must remain some bias against the conservative arm of the trial. Vroomen (6) reported epidemiologically that 75% of disc prolapses were better by 12 weeks and that 75% of the remaining 25% needed surgery by 6 months. Epidural steroid given via the caudal route has not been adequately tested and has gained a bad reputation unjustifiably, because trials have mainly been done in chronic pain, in a pain clinic setting. Members, who attended a study day at the London College of Osteopathic Medicine yesterday, agreed that their experience of caudal epidural steroid injection in acute disc prolapse accorded with Buttermans finding of long term efficacy in 50% of cases (4). Appropriate trials of this minimally invasive treatment are needed to balance the highly interventionist approach of surgeons which the evidence does not seem so clearly to support Alasdair Jacks Refs 1) Gibson JNA Surgery for disc disease. BMJ2007 ; 335:949 2) Gibson JNA et al, Surgical interventions for lumbar disc prolapse Cochrane Database Syst Rev 2007: (2) CD001350 3) Peul WC et al Surgery versus prolonged conservative treatment for sciatica N Engl J Med 2007:356:2245-56 4) Butterman GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. J Bone Joint Surg 2004; 86-A:670-9 5) Pearson A et al SPORT intervertebral disc herniation does back pain improve with surgery? In Proceedings of 34th meeting of the International Society for the Study of the Lumbar Spine, Hong Kong 10-14 June 2007: 13 www.issls.org 6) Vroomen CAJ et al. Predicting the outcome of sciatica at short term follow up BJGP 2002, 52: 119-123 Competing interests: None declared |
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Judith M Neaves, Medical Osteopath, Deputy Course Director London College of Osteopathic Medicine Holt Medical Practice, High Kelling, Holt, Norfolk, NR25 6QA
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Mr Gibson (1) concluded from the paper by Peul (2) on conservative versus surgical treatment for severe sciatica that early surgery at six to 12 weeks was better for pain relief. However the paper actually seems to indicate that the decision for surgery is best taken later, probably around 14-20 weeks. In patients with their inclusion criteria, i.e. 66% of patients with severe leg pain, 40% had recovered at about 14 weeks, but 39% of conservative group required surgery after about 20-26 weeks of leg pain. This would indicate that assessment at 6-12 weeks is not a good predictor of whether surgery or conservative treatment is the best option. The paper did mention sitting as a predictor of surgical outcome on relief of pain, and those with pain on sitting did better. This could indicate that a more detailed history might help to more effectively evaluate who would do better with surgery. There is no description of the type of examination assessment by neurologist, whether slump test and /or straight leg raising were positive in which groups, and to what extent, and presence of sensory changes or reduced/absence of reflexes, which is important in the clinical assessment of severe sciatica. Combining the results from the patients who settled before having surgery and those who needed surgery in the conservative group, it would appear that that surgery should be considered at about 14-20 weeks after onset of leg pain in patients with severe sciatica. However as the conservative group did not receive any specific advice as to managing of pain other than analgesics, no manual treatment, or caudal epidurals it would be unclear how these common interventions would compare with surgical management. There are obviously more risks to early surgery and negative cost implications in proceeding to early MRI scan and surgery, when other conservative treatment has not been sufficiently explored. 1) Gibson JNA Surgery for disc disease. BMJ2007 ; 335:949 2) Peul WC et al Surgery versus prolonged conservative treatment for sciatica N Engl J Med 2007:356:2245-56 Competing interests: None declared |
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Michael F Vagg, Orthopaedic Rehabilitation Physician Geelong Australia 3220
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I would add to the above responses that the evidence for transformainal injection is probably better than for caudal or midline(translaminar) approaches.See, for example the American Society of Interventional Pain Physicians guidelines at http://www.painphysicianjournal.com/2005/january/2005;8;1-47.pdf I do not refer for consideration of surgery unless the level of disability or pain following transforaminal injection and treatment with CBT and antineuropathic agents (not just opioids) seems justified. It is a shame that our surgical colleagues do not pay the same respect, as in their trials there is almost never reporting of the type of conservative interventions the subjects received, or even stratification of risk by psychosocial parameters which have been known for years to influence outcome far more than the choice of operation. Competing interests: None declared |
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