Predictive value of MRI in decision making for disc surgery for sciatica

Clinical article

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  • 1 Departments of Neurosurgery and Medical Decision Making, Leiden University Medical Center, Leiden;
  • | 2 Departments of Radiology and
  • | 3 Neurosurgery, Medical Center Haaglanden, The Hague; and
  • | 4 Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Object

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.

Methods

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).

Results

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).

Conclusions

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/).

Abbreviations used in this paper:

RDQ = Roland Disability Questionnaire for Sciatica; ROC = receiver operating characteristic; VAS = visual analog scale.

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Contributor Notes

Address correspondence to: Abdelilah el Barzouhi, M.D., M.Sc., Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. email: A.el_barzouhi@lumc.nl.

Please include this information when citing this paper: published online October 18, 2013; DOI: 10.3171/2013.9.SPINE13349.

  • 1

    Atlas SJ, , Keller RB, , Wu YA, , Deyo RA, & Singer DE: Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study. Spine (Phila Pa 1976) 30:927935, 2005

    • Search Google Scholar
    • Export Citation
  • 2

    Barth M, , Diepers M, , Weiss C, & Thomé C: Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome. Spine (Phila Pa 1976) 33:273279, 2008

    • Search Google Scholar
    • Export Citation
  • 3

    Beattie PF, , Meyers SP, , Stratford P, , Millard RW, & Hollenberg GM: Associations between patient report of symptoms and anatomic impairment visible on lumbar magnetic resonance imaging. Spine (Phila Pa 1976) 25:819828, 2000

    • Search Google Scholar
    • Export Citation
  • 4

    Carlisle E, , Luna M, , Tsou PM, & Wang JC: Percent spinal canal compromise on MRI utilized for predicting the need for surgical treatment in single-level lumbar intervertebral disc herniation. Spine J 5:608614, 2005

    • Search Google Scholar
    • Export Citation
  • 5

    Carragee EJ, & Kim DH: A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Correlation of outcomes with disc fragment and canal morphology. Spine (Phila Pa 1976) 22:16501660, 1997

    • Search Google Scholar
    • Export Citation
  • 6

    Cheng F, , You J, & Rampersaud YR: Relationship between spinal magnetic resonance imaging findings and candidacy for spinal surgery. Can Fam Physician 56:e323e330, 2010

    • Search Google Scholar
    • Export Citation
  • 7

    Cherkin DC, , Deyo RA, , Loeser JD, , Bush T, & Waddell G: An international comparison of back surgery rates. Spine (Phila Pa 1976) 19:12011206, 1994

    • Search Google Scholar
    • Export Citation
  • 8

    Collins SL, , Moore RA, & McQuay HJ: The visual analogue pain intensity scale: what is moderate pain in millimetres?. Pain 72:9597, 1997

  • 9

    Deyo RA: Back surgery—who needs it?. N Engl J Med 356:22392243, 2007

  • 10

    Deyo RA, , Cherkin DC, , Weinstein J, , Howe J, , Ciol M, & Mulley AG Jr: Involving patients in clinical decisions: impact of an interactive video program on use of back surgery. Med Care 38:959969, 2000

    • Search Google Scholar
    • Export Citation
  • 11

    el Barzouhi A, , Vleggeert-Lankamp CL, , Lycklama à Nijeholt GJ, , Van der Kallen BF, , van den Hout WB, & Jacobs WC, et al. : Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J Med 368:9991007, 2013

    • Search Google Scholar
    • Export Citation
  • 12

    Fardon DF, & Milette PC: Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976) 26:E93E113, 2001

    • Search Google Scholar
    • Export Citation
  • 13

    Hosmer DW, & Lemeshow S: Applied Logistic Regression ed 2 New York, John Wiley & Sons, 2000

  • 14

    Irwin ZN, , Hilibrand A, , Gustavel M, , McLain R, , Shaffer W, & Myers M, et al. : Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine (Phila Pa 1976) 30:22082213, 2005

    • Search Google Scholar
    • Export Citation
  • 15

    Jensen TS, , Albert HB, , Sorensen JS, , Manniche C, & Leboeuf-Yde C: Magnetic resonance imaging findings as predictors of clinical outcome in patients with sciatica receiving active conservative treatment. J Manipulative Physiol Ther 30:98108, 2007

    • Search Google Scholar
    • Export Citation
  • 16

    Kleinbaum DG, & Klein M: Logistic Regression: A Self-Learning Text ed 3 New York, Springer, 2010

  • 17

    Koes BW, , van Tulder MW, & Peul WC: Diagnosis and treatment of sciatica. BMJ 334:13131317, 2007

  • 18

    Lurie JD, , Tosteson AN, , Tosteson TD, , Carragee E, , Carrino JA, & Kaiser J, et al. : Reliability of magnetic resonance imaging readings for lumbar disc herniation in the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 33:991998, 2008

    • Search Google Scholar
    • Export Citation
  • 19

    Modic MT, , Masaryk TJ, , Ross JS, & Carter JR: Imaging of degenerative disk disease. Radiology 168:177186, 1988

  • 20

    Modic MT, , Steinberg PM, , Ross JS, , Masaryk TJ, & Carter JR: Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 166:193199, 1988

    • Search Google Scholar
    • Export Citation
  • 21

    Osterman H, , Seitsalo S, , Karppinen J, & Malmivaara A: Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976) 31:24092414, 2006

    • Search Google Scholar
    • Export Citation
  • 22

    Patrick DL, , Deyo RA, , Atlas SJ, , Singer DE, , Chapin A, & Keller RB: Assessing health-related quality of life in patients with sciatica. Spine (Phila Pa 1976) 20:18991909, 1995

    • Search Google Scholar
    • Export Citation
  • 23

    Peul WC, , Brand R, , Thomeer RT, & Koes BW: Improving prediction of “inevitable” surgery during non-surgical treatment of sciatica. Pain 138:571576, 2008

    • Search Google Scholar
    • Export Citation
  • 24

    Peul WC, , van Houwelingen HC, , van der Hout WB, , Brand R, , Eekhof JA, & Tans JT, et al. : Prolonged conservative treatment or ‘early’ surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial [ISRCT 26872154]. BMC Musculoskelet Disord 6:8, 2005

    • Search Google Scholar
    • Export Citation
  • 25

    Peul WC, , van Houwelingen HC, , van den Hout WB, , Brand R, , Eekhof JA, & Tans JT, et al. : Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 356:22452256, 2007

    • Search Google Scholar
    • Export Citation
  • 26

    Postacchini F: Management of herniation of the lumbar disc. J Bone Joint Surg Br 81:567576, 1999

  • 27

    Vroomen PC, , de Krom MC, , Slofstra PD, & Knottnerus JA: Conservative treatment of sciatica: a systematic review. J Spinal Disord 13:463469, 2000

    • Search Google Scholar
    • Export Citation
  • 28

    Wassenaar M, , van Rijn RM, , van Tulder MW, , Verhagen AP, , van der Windt DA, & Koes BW, et al. : Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J 21:220227, 2012

    • Search Google Scholar
    • Export Citation
  • 29

    Weber H, , Holme I, & Amlie E: The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine (Phila Pa 1976) 18:14331438, 1993

    • Search Google Scholar
    • Export Citation
  • 30

    Weinstein JN, , Lurie JD, , Tosteson TD, , Skinner JS, , Hanscom B, & Tosteson AN, et al. : Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 296:24512459, 2006

    • Search Google Scholar
    • Export Citation

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