Sciatica is the common term for lower back pain that radiates down one leg. It is a very frequent cause of missed work and disability. Sciatica is almost always caused by a lumbar disk that has been pushed out of its normal location and is impinging on a nerve.
The typical treatment for sciatica is anti-inflammatory pain medication and physical therapy. Most patients recover entirely with this conservative therapy. For those who continue to have pain, injections to numb the effected nerve frequently provide at least temporary relief. Surgery is usually only considered as a last resort, when the other treatments have failed.
A new study in this week’s New England Journal of Medicine may change the order in which these interventions are considered. The trial enrolled people who had severe, disabling sciatica for 6 to 12 weeks, and randomized them to immediate surgery (within two weeks of randomization) or to conservative treatment.
The good news is that a year later, both groups did very well, with little disability and good pain control. So in the long term, either solution is very good. Interestingly, in the early surgery group about 10% of patients recovered before surgery could be performed, again highlighting the good prognosis of this disease. In the group assigned to conservative treatment over a third eventually required surgery anyway because of unremitting pain.
The important difference between the two groups was that the group assigned to early surgery achieved pain relief much sooner than the group assigned to conservative treatment. While both groups eventually did fine a year after randomization, the surgical group had more prompt relief of symptoms.
So in patients with severe symptoms from sciatica, we should at least start considering surgery sooner, and patients should be reassured that either treatment path eventually yields good results.