Slipped vertebra and sciatica are some of the most common conditions seen by doctors in patients with back problems and two new studies suggest that timely surgery is a better way to treat them than non-surgical remedies.
The studies are published in today’s edition of the New England Journal of Medicine (NEJM).
Degenerative spondylolisthesis (DS, also known as slipped vertebra or slipped disk) is where one or more verterbra in the spine become misaligned and press on nerves in the spinal cord, resulting in severe leg pains. It generally occcurs after the age of 50. It affects around 600,000 Americans and is seen six times more often in women than in men; it is especially prevalent among African-American women.
On its own DS is usually symptom-free, but sometimes it affects the spinal canal, making it narrower (spinal stenosis) which puts pressure on the nerves resulting in pain in the legs, such as when going for a walk.
The first NEJM study, led by researchers at the Dartmouth Medical School, Lebanon, New Hampshire, US, showed that surgery was twice as effective as non-surgical treatment in reducing pain and helping patients with DS and spinal stenosis get back to normal.
Before this study, there were no controlled trials on the effectiveness of surgery to treat DS with spinal stenosis.
The researchers recruited 607 patients from 13 medical centres in 11 US states who had at least 12 weeks of symptoms which had been confirmed as DS. They were assigned to either a randomized cohort or an observational cohort.
The outcomes were measured using a range of medical, disability, general health and pain assessment questionnaires at 6 weeks, 3 and 6 months, and at 1 and 2 years.
The results showed that 372 patients had surgery within two years (decompressive laminectomy, with or without fusion) and 235 had non-surgical treatments that included physical therapy, steroid injections, and drugs.
Two years after enrollment, patients who had received surgical treatment reported significantly reduced pain and improved functionality as early as six weeks after intervention, while those who did not receive surgery reported only modest improvements.
The researchers concluded that:
“In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically.”
Sciatica is often caused by displaced spinal disks putting pressure on the sciatic nerve resulting in painful burning sensations or numbness down one side of the body, mostly in the leg. 75 per cent of cases resolve on their own without surgery, but worldwide around 1.5 million operations are carried out to remove all or part of the disk to relieve the pressure on the sciatic nerve.
The second NEJM study, led by Dutch researchers based at Leiden University Medical Center, showed that microdiskectomy surgery relieved pain faster than conservative treatments based on physical therapy and drugs, although 95 per cent of sciatica patients were free of pain within 12 months whether they had surgery or not.
Patients with sciatica are often referred to surgery if the symptoms persist more than 6 weeks, but there is little well researched information on the best time to have the operation.
The researchers randomly assigned 283 patients who had been experiencing severe sciatica symptoms for 6 to 12 weeks to one of two groups. The first group was referred for early surgery while the second group had prolonged conservative treatment (physical therapy and drugs), with surgery if needed. Both groups were monitored using questionnaires about disability, leg pain, and perceived recovery in the first year of the trial.
125 (89 per cent) of the 141 patients referred for early surgery had a microdiskectomy after an average of 2.2 weeks. 55 (39 per cent) of the 142 patients who were referred for prolonged conservative treatment had surgery after an average of 18.7 weeks.
The results showed no difference in overall disability scores during the first year. However, relief from leg pain was faster among the early surgery patients, and this group also reported a faster rate of perceived recovery. But after one year of follow up, the percentage of patients who described themselves as recovered was the same, at 95 per cent.
The researchers concluded that:
“The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery.”
“Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis.”
Weinstein, James N, Lurie, Jon D, Tosteson, Tor D, Hanscom, Brett, Tosteson, Anna NA, Blood, Emily A, Birkmeyer, Nancy JO, Hilibrand, Alan S, Herkowitz, Harry, Cammisa, Frank P, Albert, Todd J, Emery, Sanford E, Lenke, Lawrence G, Abdu, William A, Longley, Michael, Errico, Thomas J, Hu, Serena S.
N Engl J Med 2007 356: 2257-2270
“Surgery versus Prolonged Conservative Treatment for Sciatica.”
Peul, Wilco C, van Houwelingen, Hans C, van den Hout, Wilbert B, Brand, Ronald, Eekhof, Just AH, Tans, Joseph TJ, Thomeer, Ralph TWM, Koes, Bart W, the Leiden-The Hague Spine Intervention Prognostic Study Group.
N Engl J Med 2007 356: 2245-2256.
Click here for more information on Understanding Back Pain (from BBC Health).
Written by: Catharine Paddock
Writer: Medical News Today