04/05/2017
New England Journal of Medicine
CLINICAL DECISIONS
Management of Sciatica
Ramya Ramaswami, M.B., B.S., M.P.H., Zoher Ghogawala, M.D., and James N. Weinstein, D.O.
N Engl J Med 2017; 376:1175-1177March 23, 2017DOI: 10.1056/NEJMclde1701008
Comments and Poll open through April 5, 2017
CASE VIGNETTE
A Man with Sciatica Who is Considering Lumbar Disk Surgery
Ramya Ramaswami, M.B., B.S., M.P.H.
Mr. Winston, a 50-year-old bus driver, presented to your office with a 4-week history of pain in his left leg and lower back. He described a combination of severe sharp and dull pain that originated in his left buttock and radiated to the dorsolateral aspect of his left thigh, as well as vague aching over the lower lumbar spine. On examination, passive raising of his left leg off the table to 45 degrees caused severe pain that simulated his main symptom, and the pain was so severe that you could not lift his leg further. There was no leg or foot weakness. His body-mass index (the weight in kilograms divided by the square of the height in meters) was 35, and he had mild chronic obstructive pulmonary disease as a result of smoking one pack of ci******es every day for 22 years. Mr. Winston had taken a leave of absence from his work because of his symptoms. You prescribed 150 mg of pregabalin per day, which was gradually increased to 600 mg daily because the symptoms had not abated.
Now, 10 weeks after the initial onset of his symptoms, he returns for an evaluation. The medication has provided minimal alleviation of his sciatic pain. He has to return to work and is concerned about his ability to complete his duties at his job. He undergoes magnetic resonance imaging, which shows a herniated disk on the left side at the L4–L5 root. You discuss options for the next steps in managing his sciatica. He is uncertain about invasive procedures such as lumbar disk surgery but feels limited by his symptoms of pain.
TREATMENT OPTIONS
Which of the following would you recommend for Mr. Winston?
1. Undergo lumbar disk surgery.
2. Receive nonsurgical therapy.
To aid in your decision making, each of these approaches is defended in a short essay by an expert in the field. Given your knowledge of the patient and the points made by the experts, which option would you choose? Make your choice, vote, and offer your comments at NEJM.org.
Option 1: Undergo Lumbar Disk Surgery
Option 2: Receive Nonsurgical Therapy
Option 1 (69)Option 2 (69)
OPTION 1
Undergo Lumbar Disk Surgery
Zoher Ghogawala, M.D.
Mr. Winston’s case represents a common scenario in the management of symptomatic lumbar disk herniation. In this particular case, the patient’s symptoms and the physical examination are consistent with nerve-root compression and inflammation directly from an L4–L5 herniated disk on his left side. The patient does not have weakness but has ongoing pain and has been unable to work for the past 10 weeks despite receiving pregabalin. Two questions emerge: first, does lumbar disk surgery (microdiskectomy) provide outcomes that are superior to those with continued nonoperative therapy in patients with more than 6 weeks of symptoms; and second, does lumbar microdiskectomy improve the likelihood of return to work in patients with these symptoms?
The highest quality data on the topic come from the Spine Patient Outcomes Research Trial (SPORT).1 The results of the randomized, controlled trial are difficult to interpret because adherence to the assigned treatment strategy was suboptimal. Only half the patients who were randomly assigned to the surgery group actually underwent surgery within 3 months after enrollment, and 30% of the patients assigned to nonoperative treatment chose to cross over to the surgical group.2 In this study, the patients who underwent surgery had greater improvements in validated patient-reported outcomes. The treatment effect of microdiskectomy was superior to that of nonoperative treatment at 3 months, 1 year, and 2 years. Moreover, in an as-treated analysis, the outcomes among patients who underwent surgery were superior to those among patients who received nonoperative therapy. Overall, the results of SPORT support the use of microdiskectomy in this case.
Name: Kane Bixby DC
Country/Region: United States
Professional Category: Other
Relevant Financial Associations: None
Comment Title: Conservative Care
Comment:
Hard to imagine not giving this patient and epidural and a course of either physical therapy or chiropractic care with an emphasis on nerve flossing/neural stretching. Back pain comes from the disc. Leg pain comes from the nerve root.
-Stretching the nerve breaks up scar tissue and gets rid of the leg pain/unless it doesn't : ). But, why not give it a clinical trial especially in the absence of motor weakness.
-Where's Robin Mckenzie when you need him? How about some back extension therapy.
-David Drumm DC popularized the greatly underutilized disc hydration therapy consisting of 50 pelvic tilts and hour (about a minute), & 25 torso twists to each side in a sitting neutral position. 500/day
-Heat is good for business and increases inflammation, but ice is good for pain. 20 minutes 4-5 times per day.
-The great Farfan, the Editor of Spine Journal and proponent of the Farfan Torsion test to determine the direction of torsion injury to the disc, proposed to roll the patient on his/her side and adjust the patient's low back avoiding the direction of injury.
-3 grams of Fish Oil, 1500 mg of Tumeric and 1200 mg of Ginger is a much better anti-inflammatory supplement than all the NSAIDs
