1. Section Editor(s): Singh Joy, Subashni D.

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According to this study:


* Surgery and conservative treatment are similarly effective at one year.


* Patient education is a key factor in deciding upon treatment.


* Nurses can provide information and guidance on managing pain.



Sciatica-pain or tingling along the sciatic nerve-often resolves naturally. However, pain medication or microdiskectomy may be necessary to relieve prolonged sciatica. In this multicenter, prospective, randomized trial, researchers divided 283 patients who had had severe sciatica for six to 12 weeks into two groups to compare the results achieved with conservative treatment with those seen with early surgery.


Patients in the early-surgery group were scheduled for microdiskectomy soon after enrolling in the study. Patients in the conservative-treatment group received pain medication, information on their condition, and surgery if necessary. Research nurses counseled both groups on pain management and "the natural course of their illness," an intervention that is not usually available to patients.


Of 141 patients assigned to early surgery, the pain of 16 resolved prior to the scheduled procedure, leaving 125 to undergo surgery a mean 2.2 weeks later. In the conservative-treatment group, 55 patients' intractable pain caused them to have surgery after a mean 18.7 weeks.


The symptoms of those in the early-surgery group were relieved twice as quickly as those of the conservative-treatment group, but after one year, the groups had similar scores related to functional disability, leg pain, and perceived recovery.


The literature provides little guidance about when to offer microdiskectomy to patients with sciatica. "I think 16 to 20 weeks [after injury] is the earliest that physicians should first offer surgery, but a well-informed patient may ask for surgery earlier," lead author Wilco C. Peul, MD, of Leiden University Medical Center in the Netherlands told AJN recently. Peul and colleagues suggest that patients whose leg pain is intolerable and who want to recover more quickly than is possible with conservative treatment are more likely to choose surgery. At the same time, Peul warns, these patients may assume that recovery time will be shorter than it is, and if they learn to cope with the pain, they may be able to avoid surgery altogether.


With such support, Peul says, "patients learn that the goal they want to achieve with conservative treatment or surgery may take a long time. Furthermore, patients' preferences may change after they receive good information." He suggests that a standardized video could educate patients on treatment options so health care practitioners have more time to help patients make an informed decision.


Peul WC, et al. N Engl J Med 2007;356(22): 2245-56.