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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

Rapid Response:

What about the "as treated" analysis

You are to be commended for undertaking a difficult study. Alas, I must agree with Dr Greenslade's opinion that this study design and treatment protocol does not reflect present day reality. In the U.S. there is tremendous "anti-surgical" bias in the medical community and patients are told to avoid surgery by their primary care providers. Most respectable surgeons would try activity modifications, physical therapy and steroid injections among other treatments before rushing someone off to the operating room in a matter of weeks. This serves to allow those who are destined to recover spontaneously to do so.

Furthermore, this study suffers from the same flaw as the SPORT trial of Weinstein et al which was originally presented with an "intent to treat" approach and was widely criticized. Peul et al had 44% of the patients in the surgical group cross-over and undergo surgery, in which case, the intent to treat analysis defies common sense. In the very least both analyses should be clearly presented and discussed.

Competing interests: None declared

Competing interests: No competing interests

29 May 2008
Scott G Tromanhauser
Orthopaedic Spine Surgeon
The Boston Spine Group