Manipulation or Microdiskectomy for Sciatica?

A PROSPECTIVE RANDOMIZED CLINICAL STUDY


Gordon McMorland, DC,a Esther Suter, PhD,b Steve Casha, MD, PhD, FRCSC,c Stephan J. du Plessis, MD,c and R. John Hurlbert, MD, PhD, FRCSC, FACSc

ABSTRACT

Objective: The purpose of this study was to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH).

Methods: One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. Crossover to the alternate treatment was allowed after 3 months.

Results: Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measures. After 1 year, follow-up intent-to-treat analysis did not reveal a difference in outcome based on the original treatment received. However, 3 patients crossed over from surgery to spinal manipulation and failed to gain further improvement. Eight patients crossed from spinal manipulation to surgery and improved to the same degree as their primary surgical counterparts.

Conclusions: Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted. (J Manipulative Physiol Ther 2010;33:576-584)


CONCLUSIONS

Most of the patients who were considered surgical candidates for the treatment of radiculopathy from LDH improved with standardized spinal manipulative care to the same degree as those who had undergone surgery. Of those who failed spinal manipulation treatment, subsequent surgical intervention provided excellent outcome. In contrast, the 3 patients who failed microdiskectomy did not benefit from further spinal manipulative care.

Therefore, patients with symptomatic LDH failing medical management (failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) should have considered chiropractic spinal manipulative treatment as a primary treatment, followed by surgery if unsuccessful.