Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis

Abstract

Sciatica, characterized by leg or back symptoms along the sciatic nerve pathway, often manifests as a chronic condition lasting over 12 weeks. Decision-making between nonoperative treatment and immediate microdiscectomy for chronic sciatica remains challenging, due to the complex relationship between symptom duration, severity, and lumbar discectomy outcomes. In this systematic review, we conducted a comprehensive search across Scopus, PubMed, Web of Science, and the Cochrane Library, identifying relevant two-arm clinical trials up to September 2023. Rigorous screening and data extraction were performed by two independent reviewers, with study quality evaluated using the risk of bias 2 (RoB) tool. This meta-analysis incorporated four studies comprising 352 participants. Our analysis revealed that conservative treatment was associated with a significant reduction in leg pain and improvement in, SF mental, and physical scores compared to surgical intervention. However surgical treatment demonstrated significant improvement in back pain. In conclusion, our findings suggest that surgical intervention may be more effective than non-surgical treatment for chronic sciatica-related back pain. Conservative treatment significantly reduces leg pain while improving mental and physical health outcomes. Ultimately, our findings support conservative as the initial approach unless surgery is warranted, particularly in cases with neurological deficits or cauda equina syndrome.

Keywords: back vas score; chronic sciatica; conservative management; leg vas score; lumbar disc herniation; surgical management.

Figure 1. PRISMA flow diagram of the study selection process

Figure 2. RoB-2 (Quality assessment)

RoB: risk of bias RoB summary: Review authors' judgments about each risk of bias item for each included study.

Figure 3. Back pain: Surgery vs. conservative

Forest plot of standardized mean differences in back pain symptom VAS score. Std: standard mean difference; SD: standard deviation, CI: confidence interval; df: degrees of freedom; Chi²: statistical test for heterogeneity; P: p-value of Chi² (evidence of heterogeneity of intervention effects); I²: amount of heterogeneity between trials; Z: test for overall effect; Overall effect P: p-value for significance of overall effect; VAS: visual analog scale.

Figure 4. Back pain (Sensitivity test)

Forest plot of standardized mean differences in back pain symptom VAS score. Std: standard mean difference, SD: standard deviation, CI: confidence interval; df: degrees of freedom; Chi²: statistical test for heterogeneity; P: p-value of Chi² (evidence of heterogeneity of intervention effects); I²: the amount of heterogeneity between trials; Z: test for overall effect; Overall effect P: p-value for significance of overall effect; VAS: visual analog scale.

Figure 5. Leg pain: Surgery vs. conservative

Forest plot of standardized mean differences in leg pain symptom VAS score. Std: standard mean difference; SD: standard deviation; CI: confidence interval; df: degrees of freedom; Chi²: statistical test for heterogeneity; P: p-value of Chi² (evidence of heterogeneity of intervention effects); I²: amount of heterogeneity between trials; Z: test for overall effect; overall effect P: p-value for significance of overall effect; VAS: visual analog scale.

Figure 6. Leg pain (Sensitivity test)

Forest plot of standardized mean differences in leg pain symptom VAS score. Std: standard mean difference; SD: standard deviation; CI: confidence interval; df: degrees of freedom; Chi²: statistical test for heterogeneity; P: p-value of Chi² (evidence of heterogeneity of intervention effects); I²: amount of heterogeneity between trials; Z: test for overall effect; Overall effect P: p-value for significance of overall effect; VAS: visual analog scale.

Figure 7. SF-36 mental analysis

Forest plot of standardized mean differences in SF-36 mental analysis. Std: standard mean difference; SD: standard deviation; CI: confidence interval; df: degrees of freedom; Chi²: statistical test for heterogeneity; P: p-value of Chi² (evidence of heterogeneity of intervention effects); I²: amount of heterogeneity between trials; Z: test for overall effect; Overall effect P: p-value for significance of overall effect; SF: short form.

Figure 8. SF-36 score physical analysis

Forest plot of standardized mean differences in SF-36 physical analysis. Std: standard mean difference; SD: standard deviation; CI: confidence interval; df: degrees of freedom; Chi²: statistical test for heterogeneity; P: p-value of Chi² (evidence of heterogeneity of intervention effects); I²: amount of heterogeneity between trials; Z: test for overall effect; Overall effect P: p-value for significance of overall effect; SF: short-form.