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

BMJ 2008; 336 doi: (Published 12 June 2008) Cite this as: BMJ 2008;336:1355

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Author's Reply to quick responses

We thank both authors of the quick responses for their valuable comments. Dr Greenslade correctly stated that epidural corticosteroids were not applied to the conservatively treated patients in our trial. Although these might be symptom relieving for small periods of time evidence was lacking at the moment this trial was designed. As for now spinal departments prescribe corticosteroids, while results of recent studies including systematic reviews present conflicting conclusions. As it is an invasive method most physicians in our country do not routinely prescribe these injections. Yet as prolonged conservative care seems to be a valuable treatment strategy, but keeps a considerable proportion of patients suffering sciatic neuralgia for months, the option of corticosteroids should be kept open as an alternative treatment to evade surgery.

Dr. Tromanhouser is raising an intriguing point of discussion which is a debate in some scientific societies since the SPORT and the first year results of our trial have been published. In contrast to the SPORT authors our aim was to evaluate the current guideline of early surgery for sciatica and to compare the effectiveness with a strategy of prolonged conservative, including surgery when needed.

As delayed surgery was performed according to the study protocol we state that these patients were not crossovers but part of a pragmatic randomized trial comparing two strategies instead of surgical versus strict nonoperative treatment. An “intent-to-treat” analysis is in our opinion the best way to present the results but the authors certainly plan to present an as treated analysis, including a discussion of the drawbacks of the latter seemingly attractive but less rigorous methodological approach.

Competing interests: None declared

Competing interests: No competing interests

03 June 2008
Wilco C. Peul
Bart Koes, Wilbert B. van den Hout, Ronald Brand
Leiden University Medical Center