Many patients ask me if there is such a thing as waiting “to long” before initiating treatment for lumbar disc herniations and sciatica.  Some recent data from the SPORT trial suggests that patients who begin treatment within 6 months of developing sciatica generally do better than those who wait more than 6 months before beginning treatment.  Interestingly, this earlier treatment resulted in better outcomes in patients treated surgically (with microdiscectomy), and non-surgically (with epidural steroid injections).  It is also interesting to note that both surgical and non-surgical groups  demonstrated improvement, but improvement was greatest in the surgical group.



Surgical or Nonoperative Treatment for Lumbar Spinal Stenosis? A Randomized Controlled Trial Malmivaara et. al. Spine Volume 32, Number 1, pp1-8

In this study from Finland, 94 patients with lumbar spinal stenosis were randomly assigned to either surgical treatment or nonoperative treatment. All patients had symptoms of back pain radiating into the legs with fatigue and numbness worsened by walking. This group of patient’s symptoms were felt to fall in a middle range where either surgical or nonsurgical treatment could reasonably be considered.

Surgical treatment consisted of laminectomy in all cases with a small percentage also requiring a fusion for spondylolisthesis. Nonoperative care consisted of physical therapy and antinflamatory medicines, and patient education.

Both groups showed improvement during the follow-up period, but patients treated surgically reported significantly greater improvement in leg pain, back pain, and overall disability. The outcomes of surgery remained superior through the two year follow-up period.

Dr Nelson comments:

This is a very interesting study that compares the results of surgical to nonsurgical care in a group of patients with lumbar spinal stenosis with “middle of the road” or moderate symptoms that could realistically be treated surgically or nonsurgically. (More extreme cases were not included in this study).

It is a well designed study where patients were randomly assigned to treatment groups to eliminate selection bias, and sufficient patient numbers allow for meaningful conclusions.

Both surgical and nonsurgical patients improved during the 2 years of the study. However, patients receiving surgical treatment in the form of laminectomy experienced significantly better improvements in leg and back pain, and overall disability as compared to the nonsurgical group. Superior results in the surgical group remained statistically significant throughout the follow-up period, but the differences diminished over time.

These results are in line with what I have observed in my own patients. Moderate lumbar spinal stenosis can be successfully treated either surgically or nonsurgically. My general impression, however, has been that the surgically treated patients experience a greater degeree of pain relief and increased function as compared to nonsurgically treated patients. The advantages of surgery also need to be weighed against the risks of surgery, and the increased investment of resources and time associated with surgery. These are important discussions and decisions that are best made only after a thorough doctor consultation and usually discussion with trusted family and friends.

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Mark Nelson, MD