Intended for healthcare professionals


Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial

BMJ 2008; 336 doi: (Published 12 June 2008) Cite this as: BMJ 2008;336:1351
  1. Wilbert B van den Hout, health economist1,
  2. Wilco C Peul, neurosurgeon23,
  3. Bart W Koes, professor of general practice4,
  4. Ronald Brand, statistician5,
  5. Job Kievit, professor1,
  6. Ralph T W M Thomeer, neurosurgeon2,
  7. for the Leiden-The Hague Spine Intervention Prognostic Study Group
  1. 1Department of Medical Decision Making, Leiden University Medical Center, PO Box 9600, 2300RC Leiden, Netherlands
  2. 2Department of Neurosurgery, Leiden University Medical Center
  3. 3Department of Neurosurgery, Medical Center Haaglanden, the Hague, Netherlands
  4. 4Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Netherlands
  5. 5Department of Medical Statistics, Leiden University Medical Center
  1. Correspondence to: W B van den Hout hout{at}
  • Accepted 15 May 2008


Objective To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs.

Design Cost utility analysis alongside a randomised controlled trial.

Setting Nine Dutch hospitals.

Participants 283 patients with sciatica for 6-12 weeks, caused by lumbar disc herniation.

Interventions Six months of prolonged conservative care compared with early surgery.

Main outcome measures Quality adjusted life years (QALYs) at one year and societal costs, estimated from patient reported utilities (UK and US EuroQol, SF-6D, and visual analogue scale) and diaries on costs (healthcare, patient’s costs, and productivity).

Results Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083), the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024 (0.003 to 0.046), and the visual analogue scale of 0.032 (−0.003 to 0.066). From the healthcare perspective, early surgery resulted in higher costs (difference €1819 (£1449; $2832), 95% confidence interval €842 to €2790), with a cost utility ratio per QALY of €41 000 (€14 000 to €430 000). From the societal perspective, savings on productivity costs led to a negligible total difference in cost (€−12, €−4029 to €4006).

Conclusions Faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. The estimated difference in healthcare costs was acceptable and was compensated for by the difference in absenteeism from work. For a willingness to pay of €40 000 or more per QALY, early surgery need not be withheld for economic reasons.

Trial registration Current Controlled Trials ISRCTN 26872154.


  • research article, doi:10.1136/bmj.a143
  • Contributors: The participants in the Leiden-The Hague Spine Intervention Prognostic Study Group were—protocol committee: WCP, BWK, and RTWMT; steering committee: BWK, RTWMT, JAH Eekhof, JTJ Tans, WBvdH, WCP, RB, and HC van Houwelingen. WBvdH did the statistical analysis. He is guarantor for the paper. WBvdH, WCP, BWK, RB, and JK prepared the manuscript. The following research nurses collected and managed the data: M Nuyten, P Bergman, G Holtkamp, S Dukker, A Mast, L Smakman, C Waanders, L Polak, and A Nieborg. The participating hospitals and coordinating physicians were: Medical Center Haaglanden, The Hague—JTJ Tans and R Walchenbach; Diaconessen Hospital, Leiden—J van Rossum, P Schutte, and RTWMT; Groene Hart Hospital, Gouda—GAM Verheul, JE Dalman, and JAL Wurzer; Reinier de Graaf Hospital, Delft/Voorburg—JWA Sven and A Kloet; Spaarne Hospital, Heemstede/Haarlem—ISJ Merkies and H van Dulken; Bronovo Hospital, The Hague—PCLA Lambrechts and JAL Wurzer; Haga Hospital, The Hague—RWM Keunen and CFE Hoffmann; Rijnland Hospital, Leiderdorp/Alphen ad Rijn—J Haan and H van Dulken; Lange Land Hospital, Zoetermeer—R Groen and RRF Kuiters; Leiden University Medical Center, Leiden—RAC Roos and JHC Voormolen; Public Health and Primary Care, Leiden University, Leiden—JAH Eekhof.

  • Funding: Grant from the health care efficiency research programme of the Netherlands Organization for Health Research and Development.

  • Competing interest: None declared.

  • Ethical approval: Medical ethics committees of the nine participating hospitals.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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