Wisdom//

Surgery for Sciatica No Longer a Last Resort

By Sandro LaRocca, M.D.


By Sandro LaRocca, M.D.

Sciatica is by far the most common condition that leads to surgery — disc herniation causing shooting leg pain (called “radiculopathy”) is common, debilitating and can benefit greatly from surgery. But despite the severe pain that patients describe as they sit in my office, coming to terms with the fact that they may be a candidate for back surgery is still scary. So scary, in fact, that they might put it on the back burner for a while and opt for conservative pain management in the meantime.

Most of us may know someone who may have had surgery for sciatica (usually a discectomy) and still lives with pain. As you delay the decision for surgery and keep it squarely in the “Last Resort” box, those weeks turn into months and the months turn into years. The fire shooting down your leg ebbs and flows — you inadvertently become resigned to less physical activity. You have however, likely missed out on many activities you love like skiing, canoeing, jogging… life just isn’t what it used to be. Before you know it, it’s 10 years later and your crippling back pain hasn’t gotten any better.

Sciatica pain is only temporarily masked by the drugs available, and they carry enormous risk of addiction and other side effects. Over time your body becomes accustomed to the meds and, after upping the dosage quite a few times, you’re faced with only your long reserved “Last Resort” — the inevitable doom that is the operating room. Sound familiar?

This may have been the case years ago, but gone are the days of surgery being a last resort. For 16 years I’ve seen these patients with sciatica time and time again who have delayed surgery because the thought is so daunting they opt instead to go about their lives and survive with chronic and agonizing pain. Over time it gets to be too much. But surgical protocols have gotten better, convalescence much less and overall surgery for sciatica is drastically less invasive than when I started practicing. Common operations like fixing a disc herniation are now done in outpatient settings, promise better outcomes, and are helpful much earlier in the progression of the disc diseases that cause sciatic leg pain than ever before.

With so many patients needing surgery we now have excellent public health data that measures outcomes over the last 15 years for the minimally invasive disc herniation surgeries. A study published in The Spine Journal, Surgical Versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT) reveals that patients who underwent surgery to treat a lumbar disc herniation experienced less pain and had more physical function than those who sought non-operative options throughout a course of 8 years. The purpose of this prospective, randomized study was to test the long-term outcomes of a standard open discectomy versus non-operative individualized treatment, including physical therapy and home exercise instruction, education and anti-inflammatory over-the-counter drugs. In the end, statistics showed that there was no significance in outcomes with either group after year 4, but overall sciatica patients were significantly more satisfied with the pain relief and self-improvement after surgical treatment. An almost identical study posted in the European Spine Journal, Surgery Versus Conservative Management of Sciatica Due to a Lumbar Herniated Disc: A Systematic Review reports that those patients that opted for earlier surgical intervention did AS WELL AS, if not better, than those who delayed surgery several years and underwent surgery later. This was a review of several studies comparing long term conservative pain management for sciatica with surgical interventions. Statistically, there were no key differences in outcomes at 1–2 years. However, one major difference is that those who delayed surgery had more pain and quality of life compromises in that period than the group who opted for earlier surgery earlier.

This corroborates everything I have seen in my own practice and informs the discussion I have when making recommendations. There is nothing more bittersweet and rewarding than to hear the vast majority of patients return after surgery and say “I wish I hadn’t waited so long.” This affirms my advice and confirms the surgery was successful but I too wish they hadn’t had to experience those extra months or years of pain.

The bottom line: candidates for surgery should consider getting procedures done earlier. Through my experiences as a surgeon, along with the agreed upon conclusive data, the results of long-term pain management versus earlier surgical intervention are nearly identical. There is no longer a benefit from postponing most surgeries. Rather, it’s riskier and costlier to do so, not to mention very painful. The best thing that you can do for yourself or a loved one is to know where the scientific literature nets out on this in order for you and your doctor to make a decision.

References:

Jacobs WCH, van Tulder M, Arts M, et al. Surgery Versus Conservative Management of Sciatica Due to a Lumbar Herniated Disc: A Systematic Review. European Spine Journal, 2011;20(4):513–522.

Jon D. Lurie, Tor D. Tosteson, Anna N. A. Tosteson, Wenyan Zhao, Tamara S. Morgan, William A. Abdu, Harry Herkowitz, James N. Weinstein. Surgical Versus Non-Operative Treatment for Lumbar Disc Herniation. Spine, 2014; 39

Originally published at medium.com

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