When my laminotomy/bilateral foraminotomy surgery failed to fix my sciatica, I was plagued with doubts about the surgeon’s choice. I figured it was because I’d had surgery to fix the wrong thing. Perhaps my “mild central stenosis” wasn’t really the culprit. Maybe it was my “central/right paracentral disk protrusion.” Would a microdiscectomy have given me a better result?
To find out, I turned to the data. One study of 283 Dutch patients was particularly enlightening. It compared the outcomes of sciatica patients who had a microdiscectomy to address a herniated disc, to those who stuck with conservative care.
Study Design
All the patients in the study were between 18–65 years old and had sciatica for 6–12 weeks. All had disc herniations confirmed by an MRI, and all had sensations and nerve disruptions that corresponded to the expected nerve root level.
Side note: This careful selection process impressed me far more than it should have. It’s unfortunately common for studies of specific treatments to just lump everyone with sciatica in together, regardless of the cause, and often without a careful examination of the patient. Even worse is when patients are put in the catch-all category of “low back pain.” I have often wondered how useful a study can be when it doesn’t take a symptom’s etiology into account.
The patients were randomly assigned to either have a microdiscectomy surgery, or undergo conservative treatment (which in this case meant pain meds and education from a research nurse). The conservative treatment patients were then left in the hands of their family practitioners. If they saw no improvement after six months, or if they didn’t respond to pain meds, they could consider surgery.
The patients in both groups were followed for two years to assess the outcomes for disability (measured by the Roland-Morris disability questionnaire), leg pain, and back pain.
Outcomes
The patients who underwent a microdiscectomy showed a precipitous fall in their pain and disability levels immediately afterwards. Between 8–12 weeks after surgery, they showed significantly lower levels of pain and disability compared to the conservative care patients.
Unfortunately, the early gains didn’t last. Within six months, the metrics of the two groups were starting to converge, and by a year, the differences were meaningless. After two years, the differences amounted to statistical noise.
The authors noted, “After the 12 week outcome assessment, no significant differences were found between the treatment groups for any of the primary outcomes at any of the remaining assessments.”
The majority of patients in both groups (81% in the early surgery group and 79% in the conservative care group) did report satisfactory outcomes at the end of the two-year follow-up period. However, a sizeable minority (about 20% of patients in both groups) reported chronic pain and disability, and unsatisfactory results.
Many of the patients who reported good outcomes within the first year later relapsed, and sometimes ended up with worse outcomes the second time around. The idea of what counts as “recovery” therefore deserves scrutiny. The authors noted, “To solve this problem of relapse, it may be necessary to redefine ‘recovery’ as the absence of symptoms for a certain minimum period of time.”
Yeah, I’ll Have the Microdiscectomy Instead
Some patients in the conservative care group continued to have sciatica symptoms, and presumably did not want to keep suffering in the name of science. During the first year, 55 out of 142 patients in the conservative care group jumped ship and had surgery. The next year, an additional 7 patients jointed them.
The patients who crossed over into the surgery group had the same outcomes as those who were assigned to surgery in the first place. The authors wrote that, “In both treatment groups 6% of surgically treated patients had recurrent sciatica that led to a second surgical intervention during the two years of follow-up.”
Is a Microdiscectomy Worth It?
It’s been about three years since my own surgery. If I was going to write an alternate history for myself in which I had a microdiscectomy, and use the data in this article as a reference, then my story would lead to the same place I ended up in real life.
For me, the recovery time I was allowed after surgery was more important than the surgery itself. As long as I had Valium and six weeks off, my progress would most likely be the same regardless of what procedure was done or not done.
The authors were also ambivalent about the usefulness of microdiscectomies for sciatica patients. As they put it, “Since we found similar one year and two year results for both treatment strategies, neither treatment is clearly preferable. It might therefore be time to shift from the current situation of physicians’ recommendations about the need for surgery (often based on their personal preferences) to patients deciding, with the help of their physician, which treatment strategy is best for them.”
I would love to have a silver bullet (or silver scalpel) to make my sciatica go away. Unfortunately, the only treatments I’ve found that work require an investment of time and energy. On the plus side, I definitely get 10,000 steps per day.
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