Research Summary of “Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study, Journal of Manipulative and Physiological Therapeutics. Volume 33, Number 8. October 2010"
This study compared the clinical efficacy of chiropractic spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH). Sciatica caused by lumbar disk herniation (LDH) is estimated in to occur in 5.1% of men and 3.7% of women older than 30 years. Chiropractic techniques have been shown to decrease intradiscal pressure which may be why it has a positive effect on sciatica. Improvement in the patient’s predominant symptom, return to work, and persisting disability tend to be similar regardless of treatment.
Current conservative care typically includes physical therapy, analgesics, and/or epidural steroid injections. All patients included in this study had already failed three months of one or more of these traditional conservative care interventions.
This study suggests that patients should be offered chiropractic services prior to surgical intervention as this allows them to avoid surgery and allows them to improve to the same degree as those who have undergone surgery. Over 50% of patients resolve sciatica without surgical management. Yet elective lumbar diskectomy is one of the most commonly performed surgical procedures in the United States, now exceeding 250,000 cases per year. This is likely because short term outcomes of surgery are good. Yet, there are less striking differences observed in long-term follow-up of 1 year or more.
Patients with unilateral lumbar radiculopathy secondary to lumber disc herniation (LDH) at L3 — 4, L4 — 5, or L5-S1 who presented with leg-dominant symptoms with objective signs of nerve root tethering ± neurologic deficit correlated with evidence of appropriate root compression on magnetic resonance imaging.
A short synopsis of the methods are: Forty patients with symptoms of unilateral lumbar radiculopathy secondary to LDH at L3–4, L4–5, or L5-S1 who had 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. Nonresponders to primary treatment had no change in baseline scores of outcome measures within 12 weeks of spinal manipulation or surgical intervention were encouraged to crossover. After 52 weeks response to treatment was measured with a general quality of life assessment tool (Short Form [SF-36]) as well as disease-specific questionnaires (McGill Pain Questionnaire, Aberdeen Back Pain Scale, and Roland-Morris Disability Index) which were filled out at 3, 6, 12, 24, and 52 weeks after treatment
Spinal manipulative therapy consisted of side- posture, high-velocity, low-amplitude, short lever technique, which is commonly used for this type of condition. The patients also participated in a supervised rehabilitative (core stability) exercise regimen.Treatments typically required 2 to 3 visits per week for the first 4 weeks reducing to 1 to 2 visits per week for the next 3 to 4 weeks. At the 8-week mark, follow-up visits were scheduled based on the patient’s symptoms. Treatment was continued until treatment withdrawal did not create deterioration or flare up with a 2-month treatment holiday.
Overall magnitude of improvement and rate of recovery was similar for both treatment groups. The failure rate of micro- diskectomy in the relief of radiculopathy secondary to LDH is 10%-20%. The spinal manipulation failure rate is 5% to 50%. Although 40% of patients receiving spinal manipulative therapy for LDH-induced sciatica fail to achieve satisfactory relief, the risk and cost profile of operative care argues for consideration of spinal manipulative therapy before surgical intervention. There is no evidence that delaying operative treatment negatively affects the degree of improvement. Although patients who fail surgery do not benefit from further spinal manipulation intervention.
Based upon this randomized clinical study, 60% of patients with sciatica and had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention.
- Of the 40% of patients that showed unsatisfactory results with spinal manipulation, subsequent surgical intervention conferred excellent outcome.
- The 3 patients who failed surgical treatment and crossed over to spinal manipulation did not gain further improvement.
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