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Minimally Invasive Surgery Not Better for Sciatica
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"The expected treatment benefit of a faster rate of recovery from sciatica after tubular diskectomy could not be reproduced by this double-blind study," according to a report in the July 8 issue of the Journal of the American Medical Association.
Orthopedic surgeons at the Medical Center Haaglanden studied 328 people who underwent surgery for sciatic pain, and found that "the overall differences in pain intensity and recovery rates favored the conventional microdiskectomy."
Surgery is done to remove the portion of a disk that has ruptured and causes pain by pressing on the sciatic nerve. The older method, microdiskectomy, is done through a larger incision than that used for transmuscular tubular diskectomy, the minimally invasive technique that was introduced in 1997 and has gained wide popularity. But only a few studies comparing results of the two techniques have been reported.
"The reason why it [minimally invasive surgery] did not work could be because our conventional technique uses a small incision as well," said study author Dr. Mark P. Arts.
Minimally invasive surgery might still be recommended in some cases, Arts noted. "We are still working on our subgroup analysis, but possibly the tubular diskectomy is indicated in obese patients in whom a large incision and exposure is inevitable," he said.
But more patients probably will prefer the conventional approach, Arts said. "We will discuss the results of our study with our patients and their prejudiced opinion of small being better will probably change into, 'Do what's best for me,'" he said.
The results of the Dutch study were no surprise to Dr. Todd J. Albert, director of the department of orthopedic surgery at the Rothman Institute of Thomas Jefferson University in Philadelphia.
"We have people in our unit who did a similar study and found very similar results," Albert said. That study has been submitted to a medical journal for publication, he noted.
Any minimally invasive surgical technique is bound to be popular "because the public wants a less invasive procedure if it accomplishes the same thing," Albert said. "Sometimes it pans out and sometimes it doesn't. With knee surgery it has, but minimally invasive hip surgery, which was a big rage a few years ago, is not necessarily better."
In his practice, Albert said, surgery for sciatic pain is done with a procedure halfway between the conventional and minimally invasive methods. "Maybe my incision is a half a centimeter longer than for microdiskectomy," he said. "We find the window where the disk is pressing on the nerve and push it out. It is much more like the open-surgery approach."
In practical terms, the real question about surgery for sciatica is not which technique should be used but whether surgery should be done, said Dr. Michael Y. Wang, an associate professor of neurological surgery and rehabilitation medicine at the University of Miami Miller School of Medicine.
"In general, the answer is, when you have a neurological deficit or intractable pain or a problem threatening loss in terms of neurological function," Wang said. The most common reason is to ease pain, he said.
The differences shown in the Dutch study are not great enough to say that one procedure is clearly preferable over the other, Wang noted. "I use the conventional technique even though I'm a minimally invasive surgeon," he said. "For sciatica, the minimally invasive method is too complicated and involved."
The Dutch results are not directly transferable to the United States for several reasons, Wang said. For example, those who had surgery in the study stayed an average of 3.3 days in the hospital. Such a long stay is virtually unheard of in the United States, where hospital discharge is almost always done a day or two after surgery, Wang said.
SOURCES: Mark P. Arts, M.D., neurosurgeon, Medical Center Haaglanden, the Hague, Netherlands; Todd J. Albert, M.D., director, department of orthopedic surgery, Rothman Institute of Thomas Jefferson University, Philadelphia; Michael Y. Yang, M.D., associate professor, neurological surgery and rehabilitation medicine, University of Miami Miller School of Medicine; July 8, 2009, Journal of the American Medical Association
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