Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months

Bailey, Chris; Rasoulinejad, Parham; Taylor, David; Sequeira, Keith; Miller, Thomas A.; Watson, Jim; Rosedale, Richard; Bailey, Stewart I.; Gurr, Kevin R.; Siddiqi, Fawaz; Glennie, R. Andrew; Urquhart, Jennifer

doi:10.1056/nejmoa1912658

Cited by 139 publications

(154 citation statements)

References 17 publications

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“…The primary outcome at 12 months and the secondary outcomes at 6 and 12 months followed the same trend, with a superior result in the surgery group, but comparative analyses were not carried out since they were not included in the original statistical plan. In summary, in patients with sciatica for 6-12 weeks and patients with sciatica for 4-12 months, surgery renders superior results at 6 months compared to non-surgical treatment (117,120). Contrary to the results of Peul et al, Bailey et al found a trend suggesting that these differences also persist after 12 months.…”

Section: Treatment Of Lumbar Disc Herniationmentioning

confidence: 82%

“…However, with the results from paper II in mind, where a higher incidence of surgery for lumbar disc herniation was not associated with clinically relevant differences in outcome compared to a lower incidence, earlier surgery could still be beneficial for adolescents as a group, even if the numbers of surgeries would increase. This is further supported by the fact that prolonged non-surgical care has not been proven superior to surgery among adults, especially if symptoms have persisted for 4 to 12 months (120,195,196). Nevertheless, to draw firm conclusions for adolescents regarding this, there is a need of an adolescent group treated non-surgically as comparison.…”

Section: Discussionmentioning

confidence: 99%

“…Within the five-year period, eight (12%) of these 66 patients needed repeated disc surgery, compared to nine (7%) of the patients assigned to early surgery (119). In a more recent randomised controlled trial, 128 patients with sciatica persisting for 4-12 months were enrolled 1:1 to either surgery or non-surgical treatment for six months followed by surgery if needed (120). The non-surgical treatment included education in daily functioning, activity and exercise, analgesics, active physiotherapy and patients could receive an epidural glucocorticoid injection.…”

Section: Treatment Of Lumbar Disc Herniationmentioning

confidence: 99%

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Lumbar disc herniation surgery in adolescents and young adults

Lagerbäck

Möller

Gerdhem

2019

The Bone & Joint Journal

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AimsThe purpose of this study was to investigate the risk of additional surgery in the lumbar spine and to describe long-term changes in patient-reported outcomes after surgery for lumbar disc herniation in adolescents and young adults.Patients and MethodsWe conducted a retrospective study design on prospectively collected data from a national quality register. The 4537 patients were divided into two groups: adolescents (≤ 18 years old, n = 151) and young adults (19 to 39 years old, n = 4386). The risk of additional lumbar spine surgery was surveyed for a mean of 11.4 years (6.0 to 19.3) in all 4537 patients. Long-term patient-reported outcomes were available at a mean of 7.2 years (5.0 to 10.0) in up to 2716 patients and included satisfaction, global assessment for leg and back pain, Oswestry Disability Index, visual analogue scale for leg and back pain, EuroQol five-dimension questionnaire (EQ-5D), and 36-Item Short-Form Health Survey (SF-36) Mental Component Summary and Physical Component Summary scores. Statistical analyses were performed with Cox proportional hazard regression, chi-squared test, McNemar’s test, Welch–Satterthwaite t-test, and Wilcoxon’s signed-rank test.ResultsAny type of additional lumbar spine surgery was seen in 796 patients (18%). Surgery for lumbar disc herniation accounted for more than half of the additional surgeries. The risk of any additional surgery was 0.9 (95% confidence interval (CI) 0.6 to 1.4) and the risk of additional lumbar disc herniation surgery was 1.0 (0.6 to 1.7) in adolescents compared with the young adult group. Both age groups improved their patient-reported outcome data after surgery (all p < 0.001). Changes between short- (mean 1.9 years (1.0 to 2.0)) and long-term follow-up (mean 7.2 years (5.0 to 10.0)) were small.ConclusionThe risk of any additional lumbar spine surgery and additional lumbar disc herniation surgery was similar in adolescents and young adults. All patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen within both groups. Cite this article: Bone Joint J 2019;101-B:1534–1541

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Section: Treatment Of Lumbar Disc Herniationmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Section: Treatment Of Lumbar Disc Herniationmentioning

confidence: 99%

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Lumbar disc herniation surgery in adolescents and young adults

Lagerbäck

Möller

Gerdhem

2019

The Bone & Joint Journal

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“…Particularly in the case of lumbar disc herniations, the decision between surgical and conservative therapy is often a challenging and physician-dependent decision. If the patients do not suffer from neurological deficits, usually a conservative therapy is started for at least 6 weeks up to months [1]. Only when this fails, surgery is proposed.…”

Section: Introductionmentioning

confidence: 99%

“…However, the known studies are frequently difficult to generalize as the design often allows only a limited application of the results into practice. A minimum duration of symptoms of 6-8 weeks is usually required, which means that all patients with severe pain who are operated on within this period are excluded [1,2,4,7]. In this selection process, only those patients who have undergone conservative therapy over several weeks are included in studies.…”

Section: Introductionmentioning

confidence: 99%

Artificial intelligence facilitates decision-making in the treatment of lumbar disc herniations

Wirries¹,

Geiger²,

Hammad³

et al. 2020

Eur Spine J

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Purpose Apart from patients with severe neurological deficits, it is not clear whether surgical or conservative treatment of lumbar disc herniations is superior for the individual patient. We investigated whether deep learning techniques can predict the outcome of patients with lumbar disc herniation after 6 months of treatment. Methods The data of 60 patients were used to train and test a deep learning algorithm with the aim to achieve an accurate prediction of the ODI 6 months after surgery or the start of conservative therapy. We developed an algorithm that predicts the ODI of 6 randomly selected test patients in tenfold cross-validation. Results A 100% accurate prediction of an ODI range could be achieved by dividing the ODI scale into 12% sections. A maximum absolute difference of only 3.4% between individually predicted and actual ODI after 6 months of a given therapy was achieved with our most powerful model. The application of artificial intelligence as shown in this work also allowed to compare the actual patient values after 6 months with the prediction for the alternative therapy, showing deviations up to 18.8%. Conclusion Deep learning in the supervised form applied here can identify patients at an early stage who would benefit from conservative therapy, and on the contrary avoid painful and unnecessary delays for patients who would profit from surgical therapy. In addition, this approach can be used in many other areas of medicine as an effective tool for decision-making when choosing between opposing treatment options, despite small patient groups.

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Active Monitoring With or Without Endocrine Therapy for Low-Risk Ductal Carcinoma In Situ

Hwang,

Hyslop,

Lynch

et al. 2024

JAMA

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ImportanceActive monitoring for low-risk ductal carcinoma in situ (DCIS) of the breast has been proposed as an alternative to guideline-concordant care, but the safety of this approach is unknown.ObjectiveTo compare rates of invasive cancer in patients with low-risk DCIS receiving active monitoring vs guideline-concordant care.Design, Setting, and ParticipantsProspective, randomized noninferiority trial enrolling 995 women aged 40 years or older with a new diagnosis of hormone receptor–positive grade 1 or grade 2 DCIS without invasive cancer at 100 US Alliance Cancer Cooperative Group clinical trial sites from 2017 to 2023.InterventionsParticipants were randomized to receive active monitoring (follow-up every 6 months with breast imaging and physical examination; n = 484) or guideline-concordant care (surgery with or without radiation therapy; n = 473).Main Outcomes and MeasuresThe primary outcome was 2-year cumulative risk of ipsilateral invasive cancer diagnosis, according to planned intention-to-treat and per-protocol analyses, with a noninferiority bound of 0.05%.ResultsThe median age of the 957 participants analyzed was 63.6 (95% CI, 55.5-70.5) years in the guideline-concordant care group and 63.7 (95% CI, 60.0-71.6) years in the active monitoring group. Overall, 15.7% of participants were Black and 75.0% were White. In this prespecified primary analysis, median follow-up was 36.9 months; 346 patients had surgery for DCIS, 264 in the guideline-concordant care group and 82 in the active monitoring group. Forty-six women were diagnosed with invasive cancer, 19 in the active monitoring group and 27 in the guideline-concordant care group. The 2-year Kaplan-Meier cumulative rate of ipsilateral invasive cancer was 4.2% in the active monitoring group vs 5.9% in the guideline-concordant care group, a difference of −1.7% (upper limit of the 95% CI, 0.95%), indicating that active monitoring is not inferior to guideline-concordant care. Invasive tumor characteristics did not differ significantly between groups.Conclusions and RelevanceWomen with low-risk DCIS randomized to active monitoring did not have a higher rate of invasive cancer in the same breast at 2 years compared with those randomized to guideline-concordant care.Trial RegistrationClinicalTrials.gov Identifier: NCT02926911

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Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months

Cited by 139 publications

References 17 publications

Lumbar disc herniation surgery in adolescents and young adults

Lumbar disc herniation surgery in adolescents and young adults

Artificial intelligence facilitates decision-making in the treatment of lumbar disc herniations

Active Monitoring With or Without Endocrine Therapy for Low-Risk Ductal Carcinoma In Situ

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