Early surgery was better than conservative care for short-term disability and pain in sciatica.

ED FROM Peul WC, van den Hout WB, Brand R, et al. 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;336:135528. Correspondence to: Dr W C Peul, Leiden University Medical Centre, Leiden, The Netherlands; [email protected] Sources of funding: Netherlands Organisation for Health Research and Development and Hoelen Foundation, The Hague. c Clinical impact ratings: GP/FP/Primary care 6/7; Surgery/Orthopaedics 6/7; Surgery/Neurosurgery 5/7 C O M M EN TA R Y T he trial by Peul et al helps resolve some of the uncertainty about the role of discectomy in the treatment of sciatica. It has many messages for clinicians dealing with patients with sciatica due to disc herniation. Although long-term outcomes were similar for both groups, by 12 weeks those treated with early surgery had recovered faster than those treated conservatively (data not reported). This applied not only to leg pain and disability, but also to back pain. Over the ensuing 3–6 months, the early surgery group lost their initial advantage, but delayed surgery was performed in 44% of the conservative care group by the end of the trial. Unfortunately, 20% of patients reported unsatisfactory outcomes at 2 years, and 6% of those who had surgery required repeat surgery within 2 years. Conservative care was given by family practitioners, who provided analgesia, encouraged mobilisation, and referred patients to physiotherapy or back to hospital as needed. There was no mention of epidural injections, an option that may offer relief for about half of patients during the early stages of sciatica. This treatment may be less expensive and more acceptable to those who do not want surgery or cannot have surgery for other reasons. The authors rightly advocate more patient involvement in decision making about surgery because the results suggest that both treatment options are legitimate. Patients with a preference for conservative care can be assured that their long-term outcomes will not be inferior but that surgery may be indicated if their condition worsens. The same applies for those who do not have ready access to early surgery. Michael Yelland, MD Griffith University Logan City, Queensland, Australia 1. Gibson JN, Waddell G. Cochrane Database Syst Rev 2007;(2):CD001350. 2. Buttermann GR. J Bone Joint Surg Am 2004;86-A: 670–9. Repeated measurement analysis curves of mean scores for visualanalogue scale for leg pain. Reproduced with permission from Peul WC, van den Hout WB, Brand R, et al. BMJ 2008;336:1355–8. Therapeutics EBM December 2008 Vol 13 No 6 185 on 4 December 2008 ebm.bmj.com Downloaded from