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Surgical and Nonsurgical Management of Sciatica Secondary to a Lumbar Disc Herniation: Five-Year Outcomes From the Maine Lumbar Spine Study

Atlas, Steven J., MD, MPH*; Keller, Robert B., MD; Chang, YuChiao, PhD*; Deyo, Richard A., MD, MPH; Singer, Daniel E., MD*

Health Services Research
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Study Design.  A prospective cohort study.

Objective. To assess 5-year outcomes for patients with sciatica caused by a lumbar disc herniation treated surgically or nonsurgically.

Summary of Background Data.  There is limited knowledge about long-term treatment outcomes of sciatica caused by a lumbar disc herniation, particularly the relative benefits of surgical and conservative therapy in contemporary clinical practice.

Methods. Eligible, consenting patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with mailed follow-up questionnaires at 3, 6, and 12 months and annually thereafter. Clinical data were obtained at baseline from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, satisfaction, and employment and compensation status.

Results. Of 507 patients initially enrolled, 5-year outcomes were available for 402 (79.3%) patients: 220 (80%) treated surgically and 182 (78.4%) treated nonsurgically. Surgically treated patients had worse baseline symptoms and functional status than those initially treated nonsurgically. By 5 years 19% of surgical patients had undergone at least one additional lumbar spine operation, and 16% of nonsurgical patients had opted for at least one lumbar spine operation. Overall, patients treated initially with surgery reported better outcomes. At the 5-year follow-up, 70% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 56% of those initially treated nonsurgically (P < 0.001). Similarly, a larger proportion of surgical patients reported satisfaction with their current status (63%vs. 46%, P < 0.001). These differences persisted after adjustment for other determinants of outcome. The relative advantage of surgery was greatest early in follow-up and narrowed over 5 years. There was no difference in the proportion of patients receiving disability compensation at the 5-year follow-up. The least symptomatic patients at baseline did well regardless of initial treatment, although function improved more in the surgical group.

Conclusions. For patients with moderate or severe sciatica, surgical treatment was associated with greater improvement than nonsurgical treatment at 5 years. However, patients treated surgically were as likely to be receiving disability compensation, and the relative benefit of surgery decreased over time.

From the *General Medicine Division and the Medical Practices Evaluation Center, Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;

the †Maine Medical Assessment Foundation, Augusta, Maine;

and the ‡Center for Cost and Outcomes Research and the Departments of Medicine and Health Services, University of Washington, Seattle, Washington.

Supported by grants from the Agency for Health Care Policy and Research (HS-06344, HS-08194, and HS-09804).

Acknowledgment date: April 18, 2000.

Acceptance date: August 21, 2000.

Device status category: 1.

Conflict of interest category: 14.

We appreciate the assistance of Monica McLain, MA, with data analysis and Valerie Soucie with patient follow-up.

Address reprint requests to

Steven J. Atlas, MD

Medical Practices Evaluation Center

Massachusetts General Hospital

50 Staniford Street

Boston, MA 02114

E-mail: satlas@partners.org

© 2001 Lippincott Williams & Wilkins, Inc.