Spinal surgeons have striven to underwrite their surgical practice by sound evidence from clinical trials, yet data of adequate quality have not always been available. This has led to clinical dilemmas with respect to the simplest of questions, such as when should surgery be recommended for acute disc prolapse and, in degenerative disc disease, whether surgery is more effective than extended non-operative treatments? Recent trials answer these questions.

The authors of the 2007 Cochrane review of surgical interventions for lumbar disc prolapse1 conclude that surgical discectomy for carefully selected people with sciatica provides faster relief from the acute attack than conservative management. However, it was unclear whether surgery had any positive or negative effects on the natural history of the underlying disc disease. This conclusion was based primarily on one unblinded study published in 1983,2 in which around a quarter of people treated conservatively crossed over to surgery (although there was an intention to treat analysis). Patient and observer ratings showed that discectomy produced significantly better relief of low back pain and sciatica than conservative treatment …