Timing and minimal access surgery for sciatica: a summary of two randomized trials

Arts, Mark P.; Peul, Wilco C.

doi:10.1007/s00701-011-0983-8

Cited by 14 publications

(12 citation statements)

References 51 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…In particular, it was not possible to predict which patients might benefit from early consideration for invasive treatment such as surgery. 35 In a cohort of sciatica patients with at least 6 weeks' duration of symptoms, all of whom were surgical candidates, only high levels of pain and disability were associated with having surgery at some point. 12 The lack of clear and consistent factors predicting poor outcomes in patients with sciatica 11,13,14 has made it challenging to design prognostic models that can guide early treatment decision-making.…”

Section: Stratified Care Model and Rationale For The Scopic Trialmentioning

confidence: 99%

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

Foster

Konstantinou

Lewis

et al. 2020

Health Technol Assess

View full text Add to dashboard Cite

Background Sciatica has a substantial impact on patients and society. Current care is ‘stepped’, comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. Objectives The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. Design This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. Setting Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. Participants Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. Interventions In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. Main outcome measures The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost–utility analysis was undertaken over 12 months. A qualitative study explored patients’ and clinicians’ views of the fast-track care pathway to a spinal specialist. Results A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. Conclusions The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. Limitations Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. Future work Other approaches to stratified care may provide superior outcomes for sciatica. Trial registration Current Controlled Trials ISRCTN75449581. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.

show abstract

Section: Stratified Care Model and Rationale For The Scopic Trialmentioning

confidence: 99%

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

Foster

Konstantinou

Lewis

et al. 2020

Health Technol Assess

View full text Add to dashboard Cite

show abstract

“…Referred leg pain from the low back is unrelated to nerve root involvement and is considered as pain referred from any other structure such as muscle, ligament, joint or intervertebral disc. It is generally acknowledged that the differentiation between sciatica and referred leg pain is not always straightforward in clinical practice, but ultimately it is a clinical diagnosis [ 3 , 4 ]. Overall, the literature indicates that patients who complain of back and leg pain and/or sciatica suffer more severe pain and disability, take longer to recover and incur most of the indirect costs and lost workdays compared to those with back pain alone [ 1 , 5 – 7 ].…”

Section: Introductionmentioning

confidence: 99%

Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study

Konstantinou

Dunn

Ogollah

et al. 2015

BMC Musculoskelet Disord

View full text Add to dashboard Cite

BackgroundPatients with back pain radiating to the leg(s) report worse symptoms and poorer recovery than those with back pain alone. Robust evidence regarding their epidemiological profile is lacking from primary care, the setting where most of these patients will present and be managed. Our objective was to describe the characteristics of patients with back and leg pain, including sciatica, seeking treatment in primary care.MethodsAdults visiting their general practitioner with back and leg pain, of any duration and severity, were invited to participate. Participants completed questionnaires, underwent clinical assessments and received MRI scans. Characteristics of the sample are described, and differences between patients diagnosed with referred leg pain and those with sciatica are analysed.ResultsSix hundred nine patients participated; 62.6 % were female, mean (SD) age 50.2 (13.9). 67.5 % reported pain below the knee, 60.7 % were in paid employment with 39.7 % reporting time off work. Mean disability (RMDQ) was 12.7 (5.7) and mean pain intensity was 5.6 (2.2) and 5.2 (2.4) for back and leg respectively. Mean sciatica bothersomeness index (SBI) was 14.9 (5.1). Three quarters (74.2 %) were clinically diagnosed as having sciatica. In the sciatica group, leg pain intensity, neuropathic pain, pain below the knee, leg pain worse than back pain, SBI and positive MRI findings were significantly higher as compared to patients with referred leg pain.ConclusionsThis primary care cohort reported high levels of disability and pain. This is the first epidemiological study of unselected primary care patients seeking healthcare for back and leg pain. Follow-up of this cohort will investigate the prognostic value of their baseline characteristics. This new information will contribute to our understanding of the characteristics and clinical features of this population, and will underpin future research aimed at defining prognostic subgroups to enable better targeting of health care provision.

show abstract

“…Most authors report excellent outcomes regarding the resolution of radicular pain and neurological symptoms, but disappointing results leading to failed back surgery syndrome are still common [5,14], and have been related to perioperative lumbar muscle damage and postoperative epidural scarring [13]. In an attempt to improve outcomes, minimally invasive endoscopic techniques have been developed in the last few years, claiming less muscular damage and less nerve root retraction [10,11,19,29].…”

Section: Introductionmentioning

confidence: 99%

Complications of endoscopic microdiscectomy using the EASYGO! system: is there any difference with conventional discectomy during the learning-curve period?

et al. 2012

View full text Add to dashboard Cite

Between 25 and 30 cases are needed to reach the learning curve's asymptote of MED. Even during this initial learning period MED is a safe procedure, with comparable results to those obtained with conventional MSD and with a similar complication rate. The key points for reducing intraoperative complications are an adequate expertise in MSD, a precise selection of initial cases, a proper surgical planning and a careful technique, which are mandatory to avoid unnecessary neurological injury in an otherwise secure surgical approach.

show abstract

Timing and minimal access surgery for sciatica: a summary of two randomized trials

Cited by 14 publications

References 51 publications

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study

Complications of endoscopic microdiscectomy using the EASYGO! system: is there any difference with conventional discectomy during the learning-curve period?

Contact Info

Product

Resources

About