Mark P. Arts, Wilco C. Peul, Bart W. Koes, Ralph T. W. M. Thomeer and for the Leiden–The Hague Spine Intervention Prognostic Study (SIPS) Group
Although clinical guidelines for sciatica have been developed, various aspects of lumbar disc herniation remain unclear, and daily clinical practice may vary. The authors conducted a descriptive survey among spine surgeons in the Netherlands to obtain an overview of routine management of lumbar disc herniation.
One hundred thirty-one spine surgeons were sent a questionnaire regarding various aspects of different surgical procedures. Eighty-six (70%) of the 122 who performed lumbar disc surgery provided usable questionnaires.
Unilateral transflaval discectomy was the most frequently performed procedure and was expected to be the most effective, whereas percutaneous laser disc decompression was expected to be the least effective. Bilateral discectomy was expected to be associated with the most postoperative low-back pain. Recurrent disc herniation was expected to be lowest after bilateral discectomy and highest after percutaneous laser disc decompression. Complications were expected to be highest after bilateral discectomy and lowest after unilateral transflaval discectomy. Nearly half of the surgeons preferentially treated patients with 8–12 weeks of disabling leg pain. Some consensus was shown on acute surgery in patients with short-lasting drop foot and those with a cauda equina syndrome, and nonsurgical treatment in patients with long-lasting, painless drop foot. Most respondents allowed postoperative mobilization within 24 hours but advised their patients not to resume work until 8–12 weeks postoperatively.
Unilateral transflaval discectomy was the most frequently performed procedure. Minimally invasive techniques were expected to be less effective, with higher recurrence rates but less postoperative low-back pain. Variety was shown between surgeons in the management of patients with neurological deficit. Most responding surgeons allowed early mobilization but appeared to give conservative advice in resumption of work.
Abdelilah el Barzouhi, Carmen L. A. M. Vleggeert-Lankamp, Geert J. Lycklama à Nijeholt, Bas F. Van der Kallen, Wilbert B. van den Hout, Bart W. Koes and Wilco C. Peul
In a randomized controlled trial comparing surgery and prolonged conservative treatment for sciatica of 6–12 weeks' duration, more than one-third of patients assigned to conservative treatment underwent surgery. The objective of the present study was to evaluate whether MRI at baseline could have predicted this delayed surgery.
Independently evaluated qualitative and quantitative MRI findings were compared between those patients who did and those who did not undergo surgery during follow-up in the conservative care group. In addition, area under the receiver operating characteristic (ROC) curve analysis was used to assess how well MRI parameters discriminated between those who did and those who did not undergo delayed surgery (0.5–0.7 poor discrimination, ≥ 0.7 acceptable discrimination).
Of 142 patients assigned to receive prolonged conservative care, 55 patients (39%) received delayed surgery. Of the 55 surgically treated patients, 71% had definite nerve root compression at baseline compared with 72% of conservatively treated patients (p = 0.76). Large disc herniations (size > 50% of spinal canal) were nearly equally distributed between those who did and those who did not undergo surgery (25% vs 21%, p = 0.65). The size of the dural sac was smaller in the patients who underwent surgery (101.2 vs 122.9 mm2, p = 0.01). However, the size of the dural sac discriminated poorly between those who did and those who did not undergo delayed surgery (area under ROC curve, 0.62).
In patients who suffered from sciatica of 6–12 weeks' duration, MRI at baseline did not distinguish between patients who did and those who did not undergo delayed surgery. Clinical trial registration no.: ISRCTN26872154 (http://www.controlled-trials.com/ISRCTN/).
Abdelilah el Barzouhi, Annemieke J. H. Verwoerd, Wilco C. Peul, Arianne P. Verhagen, Geert J. Lycklama à Nijeholt, Bas F. Van der Kallen, Bart W. Koes, Carmen L. A. M. Vleggeert-Lankamp and For the Leiden–The Hague Spine Intervention Prognostic Study Group
This study aimed to determine the prognostic value of MRI variables to predict outcome in patients with herniated disc–related sciatica, and whether MRI could facilitate the decision making between early surgery and prolonged conservative care in these patients.
A prospective observational evaluation of patients enrolled in a randomized trial with 1-year follow-up was completed. A total of 283 patients with sciatica who had a radiologically confirmed disc herniation were randomized either to surgery or to prolonged conservative care with surgery if needed. Outcome measures were recovery and leg pain severity. Recovery was registered on a 7-point Likert scale. Complete/near complete recovery was considered a satisfactory outcome. Leg pain severity was measured on a 0- to 100-mm visual analog scale. Multiple MRI characteristics of the degenerated disc herniation were independently scored by 3 spine experts. Cox models were used to study the influence of MRI variables on rate of recovery, and linear mixed models were used to determine the predictive value of MRI variables for leg pain severity during follow-up. The interaction of each MRI predictor with treatment allocation was tested. There were no study-specific conflicts of interest.
Baseline MRI variables associated with less leg pain severity were the reader's assessment of presence of nerve root compression (p < 0.001), and assessment of extrusion compared with protrusion of the disc herniation (p = 0.006). Both variables tended to be associated, but not significantly, with satisfactory outcome during follow-up (HR 1.45, 95% CI 0.93–2.24, and HR 1.24, 95% CI 0.96–1.61, respectively). The size of disc herniation at baseline was not associated with outcome. There was no significant change in the effects between treatment groups.
MRI assessment of the presence of nerve root compression and extrusion of a herniated disc at baseline was associated with less leg pain during 1-year follow-up, irrespective of a surgical or conservative treatment. MRI findings seem not to be helpful in determining which patients might fare better with early surgery compared with a strategy of prolonged conservative care.
Clinical trial registration no.: ISRCTN26872154 (controlled-trials.com)