Level 1: Likely reliable evidence
The efficacy of early microdiskectomy for severe sciatica was evaluated in a randomized trial (N Engl J Med. 2007;356:2245-2256). Participants aged 18-65 years with severe sciatica for 6-12 weeks (N=283) were randomized to early surgery vs. conservative treatment for six months. Patients in the latter group had surgery after six months if they showed no improvement or before six months if they experienced increasing leg pain or progressive neurologic deficits. Five patients were lost to follow-up; 281 patients were analyzed.
Comparing early surgery vs. conservative treatment after one year of follow-up, 89% vs. 39% had surgery (microdiskectomy) with median time to surgery 1.9 vs. 14.6 weeks. Surgery was associated with a faster rate of perceived recovery (median time 4 vs. 12 weeks, P <.001), but an equal proportion of patients in each group—95%—had perceived recovery at one year. Among patients who had surgery, fewer than 4% had recurrent sciatica leading to repeat surgery. There were no significant differences in measures of pain and disability between the two groups in the first two weeks or the last 28 weeks. Early surgery was associated with lower disability scores at 4-20 weeks, lower leg-pain scores at 2-24 weeks, and lower back-pain scores at 8-12 weeks. Complications occurred in 1.6% of surgical patients (two dural tears and one wound hematoma); all resolved spontaneously.
However, most patients recovered without surgery. Among 395 patients who met initial inclusion criteria and were referred for MRI before randomization, 70 patients were excluded because they lacked evidence of disk herniation, 11 refused to participate, and 31 (8%) recovered before randomization. Among 140 patients who were randomized to surgery, 11% recovered before scheduled surgery (within two weeks), and 60% of 141 patients randomized to conservative treatment recovered without surgery.