Gen Med Morning Report

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Gen Med Morning Report

• SciaticaSurgical vs Medical Management
• Ritu Khanna
• Frank Chen
• 6.6.07

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Sciatica

• 5/1000 Incidence in Western countries, 1.5
  million disk surgeries performed annually
  worldwide
• 5th in disease categories in the cost of hospital
  care and accounts for a higher cost resulting
  from absenteeism from work and disability than
  any other
• An art no consensus as to how long to prolong
  conservative treatment.
• Important to appreciate the burden to the patient

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Surgery vs Prolonged Conservative Treatment for
Sciatica NEJM, 5/31/07

• A Loaded Title? Prolonged
• Overview
• Methods
• Patients
• Results
• Discussion

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Method

• Multicenter, prospective, randomized trail among
  patients with 6-12 wks of severe sciatica to
  compare early surgery vs conservative treatment
  for 6 months followed by surgery for those who do
  not have improvement

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The patients

• 283 patients, 18-65 yo, 02-05
• Radiologically confirmed disk herniation
• Dx from attending neurologist of an
  incapacitating lumbosacral radicular syndrome
  that had lasted for 6-12 wks
• Independent research nurse verified persistence
  of symptoms at time of enrollment
• For control, eliminated those with cauda equina,
  muscle paralysis, previous surgery, pregnancy,
  other coexisting disease
• Strength Many measures to ensure active disease
  at time of randomization. Control over
  subjective qualities.

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Treatment Groups

• Early surgery scheduled within 2 weeks after
  assignment, again checked for symptoms prior to
  surgery
• Removal of disk hernation by minimal unilateral
  transflaval approach with magnification
• Goal of surgery decompression of nerve root
• Rehabilitation at home with physiotherapists

• GPs provided prolonged conservative treatment to
  the patients.
• Pain control aimed at enabling patients to resume
  daily activities
• If persisted 6 mo, surgery was offered
• If leg pain was increasing, not responsive to
  medication, or if neurologic deficits progressed,
  surgery was offered earlier than 6 mo

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• Refocusing our Perspective Emphasis on what this
  means to our patients
• There is a large body of literature already
  detailing management of sciatica

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Assessment

• Patients given Roland Disability Questionnaire
  for Sciatica, visual-analogue scale for leg pain,
  7-point Likert self-rating scale of global
  perceived recovery
• Primary outcomes functional disability,
  intensity of leg pain, global perceived recovery

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A look at the Questionnaire
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Results

• 141 patients assigned to surgery - 16 recovered
  prior to date
• 142 to conservative treatment - 55 to surgery
  during 1st year after median period of 14.6 weeks
  b/c of intractable pain
• Early surgery group had higher rate of recurrent
  sciatica leading to a second surgical
  intervention 3.2 vs 1.8
• 3 surgical complications two dural tears and one
  wound hematoma resolved spontaneously. All
  achieved complete resolution of neurologic
  symptoms

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Cumulative Data from Roland Disability
Questionnaire

• Curve shows a separation in favor of conservative
  treatment initially
• After 4 weeks, there is better outcome noted in
  early-surgery group.
• Greatest difference at 8-12 wks
• But at 1 year, scores on all scales used had
  equal recovery rates in the two groups

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Results contd

• Median time to recovery was markedly faster in
  early surgery 4 vs 12 weeks.
• But both groups had similar recovery rates of 95
  at 52 weeks
• 61 recovered quickly without surgery, but 39
  continued to register high pain and disability
  scores
• Translation If theres no difference, why not
  opt for early surgery to alleviate symptoms
  sooner?

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Lastly

• Compared to other studies
• Weber study 83 with 10 yr followup outcome of
  surgery superior at 1 yr followup, at 4 years no
  difference. Did exclusion of patients with
  intolerable pain have impact?
• Weinstein in Spine Patient Outcomes Research
  Trial no difference also. But substantial
  crossover noted, 59 scheduled for surgery
  actually had surgery at variable scheduled times
  - highlights a design strength of this Peul
  study. Maybe more realistic study in that
  enrolled patients who had symptoms at least 6
  months.

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