Oral Presentation Sydney Spinal Symposium 2023

Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials (#11)

Giovanni Ferreira 1 , Chang Liu 1 , Christina Abdel Shaheed 1 , Qiuzhe Chen 1 , Ian Harris 2 , Chris Bailey 3 , Wilco Peul 4 , Bart Koes 5 , Christine Lin 1
  1. Institute for Musculoskeletal Health, Institute for Musculoskeletal Health, Sydney Local Health District & The University of Sydney, Sydney, NSW, Australia
  2. Ingham Institute of Applied Medical Research, Southwestern Sydney Local Health District and University of New South Wales, Sydney, NSW, Australia
  3. Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
  4. Neurosurgical Center Holland, Leiden University Medical Center and Haaglanden MC and Haga Teaching Hospital, Leiden, Netherlands
  5. Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, Netherlands

Objective To investigate the effectiveness and safety of surgery compared with non-surgical treatment for sciatica.

Methods: We conducted a systematic review with meta-analysis. Electronic databases were searched from inception to June 2022. Randomised controlled trials comparing any surgical treatment with non-surgical treatment, epidural steroid injections, or placebo or sham surgery, in people with sciatica of any duration due to lumbar disc herniation (diagnosed by radiological imaging) were eligible. Two independent reviewers extracted data. Leg pain and disability were the primary outcomes. Adverse events, back pain, quality of life, and satisfaction with treatment were the secondary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). Data were pooled using a random effects model. Risk of bias was assessed with the Cochrane Collaboration’s tool and certainty of evidence with the grading of recommendations assessment, development, and evaluation (GRADE) framework. Follow-up times were immediate-term (≤six weeks), short-term (>six weeks and ≤three months), medium-term (>three and <12 months), and long-term (at 12 months).

Results 24 trials were included, 12 investigated the effectiveness of discectomy compared with non-surgical treatment or epidural injections (n=1711). Very low to low certainty evidence showed that discectomy, compared with non-surgical treatment, reduced leg pain: the effect size was moderate at immediate-term (mean difference −12.1 (95% confidence interval −23.6 to −0.5)) and short-term (−11.7 (−18.6 to −4.7)), and small at medium-term (−6.5 (−11.0 to −2.1)). Negligible effects were noted at long-term (−2.3 (−4.5 to −0.2)). For disability, small, negligible, or no effects were found. A similar effect on leg pain was found when comparing discectomy with epidural steroid injections. For disability, a moderate effect was found at short-term, but no effect was observed at medium and long-term. The risk of any adverse events was similar between discectomy and non-surgical treatment (risk ratio 1.34 (95% confidence interval 0.91 to 1.98)).

Conclusion Very low to low certainty evidence suggests that discectomy was superior to non-surgical treatment or epidural steroid injections in reducing leg pain and disability in people with sciatica with a surgical indication, but the benefits declined over time.