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    Wednesday, November 22, 2006

    Eye of the Beholder: They're saying that surgery isn't superior to waiting out the pain of sciatica:

    People with ruptured disks in their lower backs usually recover whether or not they have surgery, researchers are reporting today. The study, a large trial, found that surgery appeared to relieve pain more quickly but that most people recovered eventually and that there was no harm in waiting.

    And that, surgeons said, is likely to change medical practice.


    I've never had full blown sciatica, but judging by my patients, the pain can be excrutiatingly life-limiting. Do you think this study will really change medical practice? What patient is going to buy the explanation as he writhes on the exam table that if he just waits it out, studies show that at the end of two years he'll be just as well off as if he never had surgery. I can tell you - nil. When the sciatic nerve is badly compressed, the pain is unbearable - and it often doesn't respond to pain medications. Those patients are still going to want their pain relieved quickly.

    In my neck of the woods, the approach to nerve impingement is to ask the patient if he feels he can live with the pain. If the answer is no - they get surgery. If it's yes, they get pain medications and continued physical therapy. Admittedly, the approach to low back pain varies from geographic location to geographic location, depending on the prevailing philosophy of the back surgeons in the area. \Maybe I just live in an enlightened neck of the woods.

    The studies, by the way, didn't show a clear winner between surgical and conservative treatment. The original study had so many patients switching from one treatment group to another, that its results were meaningless:

    Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.

    Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.


    The second study was an attempt to correct for the muddle, but it didn't have much success:

    Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously.

    In other words, the patients said they felt better if they had surgery instead of physical therapy, but don't believe them!
     

    posted by Sydney on 11/22/2006 06:50:00 PM 2 comments

    2 Comments:

    The headline news versions of the SPORT trial focus on the "no difference" interpretation.Reading the two articles ,however, makes it clear you get better quicker with surgery which when you have unrelenting,opiate not-that- effective-anyway neuropathic pain is very welcome.The articles also showed the current micro or almost micro surgery is much safer than your father's laminectomies and diagnoses much more precise with MRIs.

    By Blogger james gaulte, at 7:45 AM  

    I suffered for months with both the excruciating pain (think of a massive, overwhelming toothache, but in your leg), and the nagging ache. I had the laminectomy, and the instant I woke up in recovery I know I was better.

    Trust me, for people with the pain I had, waiting is not an option.

    By Anonymous Bruce Small, at 2:59 PM  

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