What Works Best to Ease the Pain of Sciatica?
Surgery can cut pain intensity by more than half among patients struggling with long-term sciatica, researchers report.
"Sciatica is the symptom of pain that radiates down the leg and is caused by compression of a nerve root in the spinal canal by a disc herniation," explained study author Dr. Chris Bailey. He's an associate professor of surgery with the Bone and Joint Institute at Western University in London, Ontario, Canada.
The U.S. National Institute of Neurological Disorders and Stroke notes that compression of the sciatic nerve -- which runs through the buttocks and down the back of the leg -- can cause a shock-like or burning sensation in the lower back. It can also trigger leg, foot and buttock pain and, in some cases, leg numbness and weakness. The condition is thought to account for roughly 5% to 10% of all lower back pain cases.
"Fortunately, in most cases sciatica will improve in weeks to a few months with non-operative care," Bailey said. "[But] our study looked at the group of patients that have persistent symptoms after that time."
Between 2010 and 2016, the investigators focused on treatment outcomes among 128 patients aged 18 to 60 who had already suffered sciatica pain for between four to 12 months.
Half were randomly assigned to undergo a discectomy, which entails the removal of tissue exerting pressure on the spinal cord or on a nerve root. Typically, the operation is a "simple" and "relatively low-risk" outpatient procedure, said Bailey, followed by a quick recovery.
The remaining patients were offered standard non-surgical care for six months. Care included an exercise regimen, painkillers, physiotherapy, function improvement training, and [for some] steroid injections for inflammation relief.
But after the study was over, roughly one-third in the non-surgical group had surgery anyway (at 11 months out, on average), the researchers said.
In the end, Bailey and his colleagues concluded "that surgery is superior to non-operative care for these patients with chronic symptoms."
Bailey acknowledged that prior research has often not identified a similar result. But he noted that "most previous research has focused on patients with a shorter course of symptoms. And because the natural history is very good for this group, the benefits of surgery are lost, as patients naturally improve with time."
By contrast, among chronic sciatica patients, "surgery [offered] a 70% greater likelihood of improvement six months afterward," he said.
Still, nine surgery patients had complications, one underwent repeated surgery, and patients in the non-surgery group who ultimately had surgery were more prone to complications, Bailey's team noted.
That thought was seconded by Dr. James Kang, professor of orthopaedic surgery at Harvard Medical School, and chairman of the department of orthopaedic surgery at Brigham and Women's Hospital in Boston.
Co-author of an accompanying editorial, Kang pointed out that one of the important things to think about when considering surgery "is that the longer the duration of the herniation and symptoms, the less likelihood of complete pain resolution."
For example, "I would state from experience that if patients have a chronic herniation up to and beyond 12 months, the potential benefit of surgery is significantly reduced if one is trying to get complete sciatica pain relief," he said.
It's also not always entirely clear which chronic sciatica patients stand to benefit the most from surgery. "There are several nuances to disc herniations," Kang said, "such as the herniated disc size, whether it is a free fragment versus contained, whether the nerve root has undergone some early damage in the three to four months that may be irreversible, as well as other factors."
So, there's no simple answer to the surgery versus non-surgery question, he noted.
"If the leg pain is great enough, patients will elect to have surgery if they have failed all other conservative treatments. It is as simple as that. And the earlier this decision is made beyond the three- to four-month mark, the better the chance of full recovery without complications," Kang said.
Bailey and his team published their findings in the March 19 issue of the New England Journal of Medicine.
There's more about sciatica and other forms of lower back pain at the U.S. National Institute of Neurological Disorders and Stroke.
SOURCES: Chris Bailey, M.D., associate professor, surgery, Bone and Joint Institute, Western University, London, Ontario, Canada; James Kang, M.D., professor, orthopaedic surgery, Harvard Medical School, and chairman, department of orthopaedic surgery, Brigham and Women's Hospital, Boston; March 19, 2020, New England Journal of Medicine