operative vs. non-operative therapy for sciatica
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Operative vs. Non-Operative Therapy for Sciatica. What does Peul et al suggest?. Sciatica: Background. Sciatica is relatively common; lifetime incidence is 13% to 40% (Frymoyer, 1992) Annual incidence of an episode of sciatica is 1% to 5% (Frymoyer, 1988) - PowerPoint PPT PresentationTRANSCRIPT
What does Peul et al suggest?
Sciatica: BackgroundSciatica is relatively common; lifetime
incidence is 13% to 40% (Frymoyer, 1992)Annual incidence of an episode of sciatica is
1% to 5% (Frymoyer, 1988)Ancient Greeks used the term sciatica to
describe pains or “ischias” (Stafford et al, 2007)Initially known as Cotugno’s Disease after the
anatomist who wrote the first book on the condition in the 1700’s (Delaney, 1980)
Sciatica: Epidemiology
Source: Stafford et al, 2007
Source: www.google.com/health
Sciatica: PathophysiologySeveral etiologies proposed:
(1) Inflammatory (1) Phospholipase A2 (Saal et al, 1990; Franson et al,
1992)(2) TNF-α (Karppinen et al, 2003)
(2) Immune-mediated(3) Mechanical
Sciatica: Inflammatory?
Stafford et al, 2007
Sciatica: Immune-mediated?Raised antibody levels to glycosphingolipids
were detected in (Brisby et al, 2002): 71% of patients with acute sciatica61% at 4 yr follow-up54% of those undergoing discectomy
Peul et al, 2007, New England Journal of Medicine
BackgroundNo consensus on how long non-surgical
(“conservative”) therapy should be tried prior to surgery (Luijsterburg et al, 2004)
Authors suggest “sociocultural preferences” account for differences
Dutch guidelines: after 6 weeks of conservative treatment, offer surgery
In the US, largely practitioner dependent in terms of referral to physical therapy vs. referral to surgery
US vs. Switzerland expert panels differ little (Vader et al, 2000)
Methods: EligibilityMulticenter, prospective, randomized trialInclusion Criteria: (1) 18 to 65 years (2)
radiologically confirmed disc herniation (3) sciatica lasting 6-12 weeks
Exclusion Criteria: (1) Cauda equina (2) Muscle paralysis (3) Absent movement against gravity (4) Similar sciatica episode within 12 months (5) Previous spine surgery (6) Bony stenosis (7) Spondylolisthesis (8) Pregnancy (9) Severe co-existing disease
Randomization via computer-generated block scheme
Methods: Treatment General or spinal anesthesia Minimal, unilateral transflaval approachAnnular fenestration with curettage and
removal of disk material No attempt to perform a subtotal diskectomy Home rehabilitation supervised by
physiotherapists using standardized protocol
Methods: ConservativeGP informed patients of favorable prognosis and
encouraged them to visit website with more information
Pain medication was adjusted according to previous study protocol (Peul et al, 2005)
Patients fearful of moving were referred to physiotherapists
Microdiskectomy was offered to patients with sciatica persisting for 6 months
Patients with (1) increasing leg pain non-responsive to pain meds (2) progressive neurologic deficits were offered surgery earlier than 6 months
Methods: SurveysRoland Disability Questionnaire for Sciatica (Ostelo et
al, 2003)Visual Analogue Scale for Leg Pain (Capodaglio, 2001)Likert Self-Rating (Dawes, 2008)Primary outcomes: (1) Functional disability (2)
Intensity of leg pain (3) Global perceived recoverySecondary outcomes: recorded at 8, 26, and 52 weeksSecondary outcome visits: (1) neuro exam (2)
independent research nurse made (a) functional (b) economic observations
SF-36Sciatica Frequency and Bothersomeness Index (Grovle
et al, 2008)
Methods: Surveys Cont’dProlo functional observational assessmentProlo economic observational assessmentMcGill affective score
Methods: StatsPrimary aims:
Disease specific disability with respect to daily functioning (Roland and VAS)
Median time to recovery (Likert scale as a function of time)
Power of .9 with two-tailed significance at .05 level to detect at least a 3 point difference on Roland
SPSS version 12Hazard ratio to compute speed of recovery
Hazard Ratio “A hazard ratio of 2 means that treatment
will cause the patient to heal faster, but in a very specific sense. In the context of hazard ratio, “fast” means that a treated patient who has not yet healed by a certain time has twice the chance of being healed at the next point in time compared to someone in the control group” (Spruance et al, 2004)
DiscussionMicrodiskectomy techniqueSubgroups: sciatica when sittingAdequate reflection of productivity costs and
quality of life missing for the “conservative” groupObjective information on the course of symptomsLimited generalizability:
(1) Nurses guided pain management in conservative group
(2) Lack of blinding of patient and practitioner(3) Sampling timepoints may have underestimated time
to recovery
CritiqueBlinding and the Placebo Effect?
PatientsIndependent research nurse
Scale to analyze “median time to recovery”Limited generalizability (Netherlands vs. US)Intention to treat (Hollis et al, 1999)Hazard ratio (Spruance et al, 2004)Physiologic mechanisms behind sciatica
Implications and Future DirectionsHealth reform and rationingEpidural injections for sciatica?Does type of surgery (e.g. MIS) influence the
outcome?
References Frymoyer J. Lumbar disc disease: epidemiology. Instr Course Lect 1992; 41: 217–23 Frymoyer JW. Back pain and sciatica. N Engl J Med 1988; 318: 291–300 Stafford MA, Peng P Hill DA Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J
Anaesth. 2007 Oct;99(4):461-73. Epub 2007 Aug 17. Delaney TJ, Rowlingson JC, Carron H, Butler A. Epidural steroid effect in nerves ad meninges. Anesth Analg 1980; 59: 610–4 Saal JS, Franson RC, Dobrow R, White AH, Goldthwaite N. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine
1990; 15: 674–8 Franson RC, Saal JS, Saal JA. Human disc phospholipase A2 is inflammatory. Spine 1992; 17: 5129–32 Karppinen J, Korhonen T, Malmivaara A, et al. Tumor necrosis factor-a monoclonal antibody, infliximab, used to manage severe sciatica. Spine 2003;
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against a clinical guideline. Eur Spine J. 2004 Dec;13(8):719-23. Epub 2004 Apr 29. Ostelo RW, de Vet HC, Vlaeyen JW, Kerckhoffs MR, Berfelo WM, Wolters PM, van den Brandt PA. Behavioral graded activity following first-time
lumbar disc surgery: 1-year results of a randomized clinical trial. Spine (Phila Pa 1976). 2003 Aug 15;28(16):1757-65. Capodaglio EM. Comparison between the CR10 Borg's scale and the VAS (visual analogue scale) during an arm-cranking exercise. J Occup Rehabil.
2001 Jun;11(2):69-74Grøvle L, Haugen AJ, Keller A, Natvig B, Brox JI, Grotle M. Reliability, validity, and responsiveness of the Norwegian versions of the Maine-Seattle Back Questionnaire and the Sciatica Bothersomeness and Frequency Indices. Spine (Phila Pa 1976). 2008 Oct 1;33(21):2347-53.
Spruance, Spotswood L., Reid, Julia E., Grace, Michael, Samore, Matthew Hazard Ratio in Clinical Trials Antimicrob. Agents Chemother. 2004 48: 2787-2792
Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ. 1999 Sep 11;319(7211):670-4.