2. treated in contemporary clinical practice, the only pro-
spective comparison of surgical and nonsurgical treat-
ment is from an observational study.10
The Maine Lum-
bar Spine Study has previously reported results after 1
and 5 years11,12
that were similar to those from the
Weber study.8
The goal of the current study was to assess
the relative benefits of surgical and nonsurgical treat-
ment over a 10-year follow-up period using a broad
range of validated patient-reported outcome measures.
Materials and Methods
Details about the Maine Lumbar Spine Study design and meth-
ods, and 1- and 5-year outcomes for patients with sciatica due
to an intervertebral disc herniation have been previously pub-
lished.10 –12
The study prospectively followed patients treated
by orthopedic surgeons, neurosurgeons, and occupational
medicine physicians in community-based practices throughout
the state of Maine. Treatment, either surgical or nonsurgical
care, was determined in a routine clinical manner by the patient
and the physician. Almost all patients undergoing surgery had
an open discectomy to remove an extruded disc fragment or
herniation.11
Percutaneous discectomies were uncommon
(4.3%), and no patient underwent fusion at the initial opera-
tion. For nonsurgically treated patients, back exercises, physi-
cal therapy, bedrest, spinal manipulation, narcotic analgesics,
and epidural steroids were most frequently used, with most
patients receiving several treatments.11
Study Population. The diagnosis of sciatica resulting from an
intervertebral disc herniation was based on the physician’s as-
sessment. Specific radiographic findings were not required for
study entry. To restrict the study to patients for whom surgery
would be elective and acceptably safe, patients were excluded if
they had prior lumbar spine surgery, cauda equina syndrome,
developmental spine deformities, vertebral fractures, spine in-
fection or tumor, inflammatory spondylopathy, pregnancy, or
severe comorbid conditions. A total of 507 patients were en-
rolled from 1990 to 1992, with enrollment stratified to obtain
roughly equal numbers of surgical and nonsurgical patients.10
Patients who initially chose nonsurgical treatment but under-
went surgery before the first follow-up evaluation at 3 months
were included in primary analyses as having been surgically
treated (n ϭ 38, 14%).11,12
Study Protocol. For eligible patients, written informed con-
sent was obtained at study entry. Baseline interviews were con-
ducted in person by trained research assistants. Follow-up was
obtained by mailed questionnaires at 3, 6, and 12 months, and
then yearly through 10 years. Physicians completed a detailed
baseline questionnaire including history, physical and neuro-
logic findings, diagnostic procedure results, and planned treat-
ment. Baseline imaging studies (CT, MRI, or myelogram) were
ordered as directed by the treating physicians, and about half
were available for independent review by a neuroradiologist.11
All study activities were approved by the Institutional Review
Boards at the University of Washington, Seattle, ME Medical
Center, Portland, ME, and Massachusetts General Hospital,
Boston, MA.
Baseline Variables and Findings. Baseline findings, includ-
ing demographic information, employment and disability sta-
tus, comorbid conditions, past spine history, physical exami-
nation and imaging findings, symptoms, and functional status,
have been reported previously.11,12
Patients initially receiving
surgical or nonsurgical treatment were similarly young,
healthy, predominantly male, had not graduated from college,
had been employed in the past month, and had symptoms for
less than 6 months (Table 1). Patients treated surgically were
less likely than patients treated nonsurgically to be receiving
Workers’ Compensation but were more likely to have abnor-
mal physical findings, moderate or severe findings on imaging
studies, severe back and leg pain, and greater back-related and
overall disability (Tables 1 and 2). Despite worse back-related
symptoms and findings, surgically treated patients had better
baseline SF-36 general health perceptions. Patients not com-
pleting 10-year follow-up (n ϭ 107) had similar baseline char-
acteristics as those not completing follow-up at 1 and 5
years.11,12
Nonresponders tended to be younger and were sig-
nificantly more likely to be male, smokers, not married or
working, and less educated (data not shown). Among other
baseline characteristics, nonresponders also had significantly
worse low back pain severity and general health perceptions.
Table 1. Patient Characteristics and Features of Back
Disorder at Baseline Evaluation
Characteristic*
Surgical
(n ϭ 217)
Nonsurgical
(n ϭ 183) P†
Age (yr) ͓mean (SD)͔ 42.2 (11.0) 41.8 (11.7) 0.77
Gender, male 63.6 58.5 0.29
Education, college graduate 34.1 26.8 0.11
Smoking status, never or
quit Ͼ 6 mo ago
59.3 63.9 0.34
Comorbid illnesses, yes‡ 26.7 21.9 0.26
Employed in past 4 wk 59.9 50.3 0.05
Receiving or applying for
Workers’ Compensation
29.2 48.6 Ͻ0.001
Past episodes of back pain,
none
20.7 23.0 0.59
Positive straight leg raise test 72.8 47.8 Ͻ0.001
Abnormal examination findings
͓mean (SD)͔ §
1.1 (0.9) 1.4 (1.0) Ͻ0.001
Radiographic image reviewed
(n)
115 75
Moderate or severe findings# 82.6 61.3 0.001
Quebec classification, category
4 or 6**
49.1 30.2 Ͻ0.001
Length of current episode,
Ͻ 6 mo
70.5 70.9 0.94
Unilateral leg pain, yes 85.3 71.1 Ͻ0.001
SF-36 score (0–100), mean (SD) ††
Physical function 31.4 (25.5) 46.7 (26.5) Ͻ0.001
Bodily pain 19.2 (15.6) 35.5 (23.6) Ͻ0.001
Role-emotional 48.2 (43.3) 57.4 (43.7) 0.04
Mental health 61.4 (18.6) 66.6 (20.1) 0.009
General health 79.1 (17.3) 72.8 (19.1) Ͻ0.001
*The data are expressed as the percentage, except as noted. Denominators
differ slightly among variables because not all patients answered each ques-
tion on the survey.
†P values compare surgical and nonsurgical treatment groups using Fisher’s
exact test or t test.
‡Any self-reported chronic pulmonary disease, heart disease, stroke, cancer,
or diabetes.
§The mean no. of positive physical examination findings for a patient, includ-
ing unilateral strength, sensation, or reflex abnormality (range, 0–3 findings).
¶Any computerized tomography, magnetic resonance imaging, or myelogram
available for independent review.
#Global rating from normal to severe by study neuroradiologist blinded to
treatment group and clinical information.
**The Quebec classification system defines 11 categories including sciatica
with distal extremity radiation and neurologic findings (category 4), or the
above with radiographic findings of nerve root compression (category 6).
††Higher scores indicate better function.
928 Spine • Volume 30 • Number 8 • 2005
3. Outcome Measures. On each follow-up questionnaire, pa-
tients were asked to describe improvement in low back and leg
pain relative to baseline. Responses ranged from “much
worse” to “completely gone” on a 7-point scale. The primary
symptom outcome was improvement in the patient’s predom-
inant symptom, either back or leg pain, as indicated at baseline.
The outcome was categorized as improved if the response was
“better,” “much better,” or “completely gone,” the same if the
response was “about the same” or “a little better,” and worse
if the response was “a little worse” or “much worse.” To assess
for a more definitive positive treatment outcome, symptom re-
sponses were also classified as “much better” or “completely
gone” compared with other responses.
Reports of symptoms in the past week were assessed at
baseline and follow-up, including the frequency (from 0 “not at
all” to 6 “always”) and bothersomeness (from 0 “not bother-
some” to 6 “extremely bothersome”) of low back pain, leg
pain, leg or foot weakness, leg numbness, and pain in the back
or leg while sitting. Sciatica frequency and bothersome indexes,
each with scores ranging from 0 to 24, were created by sum-
ming the four leg-related questions.13
Back-specific functional
status was measured using the modified Roland disability
scale.13
General health perceptions were assessed with a ques-
tion from the Medical Outcomes Study Short Form 36-item
questionnaire, “In general, would you say your health is” “ex-
cellent” (1) to “poor” (5).14
For each variable, higher scores
indicate more severe symptoms or dysfunction.
Patients were considered to be satisfied with their current
state if they replied that they were “delighted,” “pleased,” or
“mostly satisfied” on a 7-point scale. Satisfaction with treat-
ment decisions was assessed at follow-up visits by determining
if patients would still choose their initial treatment. Disability
and work status were assessed at follow-up and are reported
according to whether or not the patient was receiving Workers’
Compensation at baseline. Finally, first operations for patients
initially treated nonsurgically and reoperations for those
treated surgically were assessed for all patients from physician
office records, state hospital discharge data, and patient re-
sponses to follow-up surveys and telephone contact.
Analysis. The rating of current findings at follow-up used cat-
egorical responses, so distributions were directly compared be-
tween treatment groups using 2
tests or Fisher’s exact tests.
Although baseline clinical features of the treatment groups dif-
fered, there was considerable overlap. To adjust for baseline
differences between the two treatment groups, logistic regres-
sion models were used to estimate the marginal effect of surgi-
cal compared with nonsurgical treatment for the predominant
symptom and satisfaction with the current state outcomes at 10
years. Changes in symptoms and functional status were as-
sessed by subtracting results at 10-year follow-up from those at
baseline, and linear regression models were used to examine the
effect of treatment group after controlling for baseline score. In
all analyses, the effect of the patient’s initial treatment decision,
either surgical or nonsurgical care, was assessed. Reoperation
rates among patients initially undergoing surgery and surgical
crossover rates among those initially receiving nonsurgical
treatment were assessed using survival analysis methods (in this
case, time-to-an-event analysis) over 10 years. Secondary anal-
yses of treatment effect considered the actual treatment re-
ceived at 10-year follow-up.
To examine the pattern of change over time, repeated-
measures analysis was performed using data from all follow-
ups between 2 and 10 years (n ϭ 468, 92%). Mixed-effects
models and logistic regression models with Generalized Esti-
mating Equations were used to model the correlation structure
of the repeated-measures within each patient.15
The treatment-
by-time interaction was used to test how treatment effect dif-
fered over time in these models. All analyses were performed
using a commercial software package (Statistical Analysis Sys-
tem, SAS Institute, Cary, NC).
Results
Thirty of 507 eligible patients enrolled in the study died
during follow-up; a 93.4% 10-year survival rate (using
survival analysis). Among those alive after 10 years, out-
comes were available for 400 of 477 (84%) patients: 217
Table 2. Change in Symptoms and Functional Status From Baseline to 10-Yr Follow-up According to Initial Treatment
Surgical Treatment* Nonsurgical Treatment*
Variable ͓mean score (SD)͔† Baseline‡ 10 Yr‡ Change§ Baseline‡ 10 Yr‡ Change§ P¶
Low back pain in the past week
Frequency score 4.4 (2.0) 1.9 (1.8) Ϫ2.5 (2.3) 3.7 (2.1) 2.3 (1.8) Ϫ1.4 (2.4) Ͻ0.001
Bothersome score 4.2 (2.0) 1.9 (2.0) Ϫ2.3 (2.5) 3.5 (2.0) 2.3 (1.8) Ϫ1.2 (2.4) 0.007
Leg pain in the past week
Frequency score 5.1 (1.4) 1.5 (1.8) Ϫ3.6 (2.1) 3.5 (2.1) 1.8 (1.7) Ϫ1.7 (2.3) Ͻ0.001
Bothersome score 5.3 (1.4) 1.5 (1.9) Ϫ3.8 (2.2) 3.6 (2.2) 1.7 (1.8) Ϫ1.9 (2.4) 0.002
Sciatica Index
Frequency 17.8 (5.2) 6.1 (6.6) Ϫ11.8 (7.6) 12.2 (6.6) 6.7 (6.0) Ϫ5.5 (7.9) 0.01
Bothersome 17.6 (5.1) 5.7 (6.7) Ϫ11.9 (7.4) 11.8 (6.4) 6.1 (6.0) Ϫ5.8 (7.4) 0.004
Modified Roland scale 17.7 (4.0) 6.0 (7.0) Ϫ11.7 (7.2) 13.3 (5.9) 7.6 (7.0) Ϫ5.8 (7.6) Ͻ0.001
SF-36 general health perceptions** 2.2 (1.1) 2.4 (1.0) 0.26 (1.2) 2.4 (1.0) 2.6 (0.9) 0.25 (1.1) 0.20
*The no. of patients reporting each variable ranged from 188 to 217 for surgical patients and 152 to 183 for nonsurgical patients.
†Low back and leg pain scores range from 0 to 6. Sciatica frequency and bothersome indices are the sum of 4 questions (each response scored from 0 to 6): leg
pain, leg or foot weakness, leg numbness, and pain in the back or leg while sitting. Sciatica Index scores range from 0 to 24, modified Roland Scale scores range
from 0 to 23, and SF-36 general health perceptions range from 1 to 5.
‡Higher mean scores at baseline and at 10 yr indicate worse symptoms or function for all variables.
§Change is calculated as score at 10 yr minus score at baseline. Negative values indicate improvement for all variables.
¶P values compare the change between surgical and nonsurgical treatment groups using multiple linear regression models that control for baseline score.
**Assessed using the SF-36 question: “In general, would you say your health is” “excellent” (1) to “poor” (5).
929Ten-Year Outcomes of Sciatica • Atlas et al
4. of 255 (85%) initially treated surgically and 183 of 222
(82%) initially treated nonsurgically.
Patients’ Global Evaluation at 10 Years
Patients were asked to contrast the current status of their
low back and leg pain symptoms at 10 years with that at
baseline. A slightly higher percentage of patients treated
surgically reported improved low back pain compared
with patients treated nonsurgically (69% vs. 59%, P ϭ
0.11), but leg pain improvement was similar in both
treatment groups (Table 3). The predominant pain
symptom, either low back or leg pain based on the pa-
tient’s report at entry, was improved in 69% of surgical
patients compared with 61% of nonsurgical patients
(P ϭ 0.19). However, the predominant symptom was
reported to be “much better” or “completely gone” in
56% of surgical patients compared with 40% of nonsur-
gical patients (P ϭ 0.006).
Although improvement in the primary symptom mea-
sures was not significantly different between treatment
groups, patient satisfaction at 10-year follow-up was sig-
nificantly better among those treated surgically (Table
3). Satisfaction with the patient’s current state was re-
ported by 70.5% of surgically treated patients versus
55.5% of nonsurgically treated patients (P ϭ 0.002).
Eighty-seven percent of patients treated surgically would
still definitely or probably choose their initial treatment
compared with 76% of those treated nonsurgically (P ϭ
0.006).
Work and disability outcomes were similar regardless
of initial treatment received (Table 3). Among patients
receiving Workers’ Compensation at study entry, 19%
of surgically treated and 17% of nonsurgically treated
patients were receiving some form of disability compen-
sation at 10 years (P ϭ 0.83). Patients who were working
at study entry were very unlikely to be receiving disabil-
ity compensation at 10 years (5%), regardless of treat-
ment. The percentage of patients working at 10-year fol-
low-up was also similar regardless of initial work,
disability, or treatment status.
Change in Symptoms and Functional Status Over
10 Years
Patients rated the frequency and bothersomeness of low
back pain and leg symptoms in the past week at baseline
and 10 year follow-up (Table 2). For both low back pain
and leg pain, surgically treated patients rated the fre-
quency and severity of symptoms as worse at baseline
evaluation and better at 10-year follow-up compared
with patients treated nonsurgically. The frequency and
bothersomeness of sciatica symptoms were also worse at
baseline and better at follow-up for surgical patients. For
each symptom question, the change in symptoms at 10
years was significantly greater among surgically treated
patients than among nonsurgically treated patients (all
P Ͻ 0.01). Similarly, surgically treated patients reported
significantly greater improvement in back-specific func-
tional status using the modified Roland scale (11.7 point
improvement vs. 5.8 point improvement, P Ͻ 0.001).
Although back-related symptoms and function im-
proved over 10 years, general health perceptions wors-
ened slightly to a comparable degree in both treatment
groups.
Independent Predictors of Symptom Improvement and
Satisfaction at 10 Years
Initial treatment was not randomly assigned. At baseline,
surgical patients on average had more severe symptoms
and findings than nonsurgical patients. Variables in all
models included treatment group, age, and sex as well as
independent baseline predictors of outcome. Logistic re-
gression models examining the independent effect of
treatment on the patients’ predominant symptom and
satisfaction with the current state at 10 years confirmed
the unadjusted findings in Table 3 (Table 4). Specifically,
when “improved” was defined as a patient response of
“better,” “much better,” or “completely gone,” surgical
treatment was not a statistically significant independent
predictor of the predominant symptom outcome (odds
ratio [OR], 1.4; 95% confidence interval [CI], 0.9–2.3).
However, if symptom improvement was restricted to re-
Table 3. Patient Reported Improvement in Symptoms and
Satisfaction and Disability Status at
10-Year Follow-up
10-Year Outcomes (%) Surgical Nonsurgical P*
Low back pain vs. baseline† (n ϭ 212) (n ϭ 179) 0.11
Improved 68.9 58.7
Same 20.3 27.9
Worse 10.9 13.4
Leg pain compared to baseline† (n ϭ 208) (n ϭ 171) 0.56
Improved 69.2 64.3
Same 19.2 23.4
Worse 11.5 12.3
Predominant symptom compared
to baseline†‡
(n ϭ 207) (n ϭ 175) 0.19
Improved 69.1 61.1
Completely gone 32.9 16.6
Much better 22.7 23.4
Better 13.5 21.1
Same 18.4 25.7
Worse 12.6 13.1
Satisfied with current state, yes§ 70.5 55.5 0.002
Still choose the same initial
treatment, yes¶
86.6 75.7 0.006
If receiving Workers’
Compensation at entry,
current status
(n ϭ 63) (n ϭ 88)
Receiving any disability
compensation
19.1 17.1 0.83
Working 81.0 75.0 0.43
If employed at entry, current
status
(n ϭ 130) (n ϭ 92)
Receiving any disability
compensation
5.4 5.5 1.00
Working 81.5 82.6 0.86
*P values assessed using Fisher’s exact or 2
tests for categorical variables.
†Symptom severity was reported to be improved if the response was “bet-
ter” to “completely gone,” the same if the response was “about the same”
or “a little better,” and worse if the response was “a little worse” or “much
worse.”
‡The predominant symptom, either back or leg pain, as rated by the patient at
baseline.
§N ϭ 217 for surgical and N ϭ 182 for nonsurgical cohorts.
¶N ϭ 217 for surgical and N ϭ 181 for nonsurgical cohorts.
930 Spine • Volume 30 • Number 8 • 2005
5. sponses of “much better” or “completely gone,” surgical
treatment was significantly associated with a favorable
outcome (OR, 2.1; 95% CI, 1.2–3.7). Patients treated
surgically were also more likely to be satisfied with their
current state (OR, 2.2; 95% CI, 1.4–3.6).
Depending on the outcome variable, several other
baseline factors were independently associated with out-
come (Table 4). In all models, receiving Workers’ Com-
pensation at baseline was associated with worse out-
comes (OR, 0.4–0.6). Greater severity of baseline
symptoms was also associated with worse outcomes, al-
though the particular symptom measure (low back pain
or sciatica bothersomeness) varied depending on the out-
come selected (OR, 0.7–0.8). On the other hand, better
SF-36 general health status at study entry was associated
with improved symptoms, while SF-36 better mental
health status was associated with higher satisfaction at
10 years (OR, 1.2 per 10-point change).
Time Course of Outcomes
Mean scores at baseline and at each follow-up over 10
years for the frequency of sciatica symptoms and back-
specific functional status are shown in Figure 1. The per-
centage of patients reporting satisfaction with their cur-
rent state at each follow-up is shown in Figure 2. As
previously reported,12
most of the improvement in out-
come due to surgery was seen shortly after patients’ entry
into the study. From years 2 through 10, there was a
small but significant improvement in the frequency of
sciatica symptoms and satisfaction over time in both
Table 4. Independent Baseline Predictors of Patient Symptoms and Satisfaction at 10 Yr
Baseline Features*
Predominant Symptom†
Satisfied With Current State‡Improved ϭ At Least Better Improved ϭ At Least Much Better
OR (95% CI) P OR (95% CI) P OR (95% CI) P
Initial treatment, surgical
Unadjusted 1.4 (0.9–2.2) 0.10 1.9 (1.2–2.8) 0.003 1.9 (1.3–2.9) 0.002
Adjusted model 1.4 (0.9–2.3) 0.17 2.1 (1.2–3.7) 0.01 2.2 (1.4–3.6) 0.001
Education, college graduate NS 2.3 (1.4–3.9) 0.002 NS
Married or living together NS 2.0 (1.1–3.7) 0.02 NS
Receiving Workers’ Compensation 0.6 (0.4–0.9) 0.02 0.4 (0.2–0.6) Ͻ0.001 0.5 (0.3–0.8) 0.002
Comorbid illnesses, yes § NS NS 0.5 (0.3–0.9) 0.02
Abnormal examination findings ¶ NS 1.3 (1.0–1.7) 0.01 NS
Location of pain, unilateral leg NS 2.6 (1.4–4.9) 0.003 NS
Low Back Pain Score (0–12), per 2-point
increment
0.8 (0.7–0.9) 0.002 NS 0.8 (0.7–0.9) 0.002
Sciatica Bothersome Index (0–24), per
4-point increment
NS 0.7 (0.6–0.8) Ͻ0.001 NS
SF-36 General Health (0–100), per 10-
point increment
1.2 (1.1–1.4) 0.004 1.2 (1.1–1.4) 0.005 NS
SF-36 Mental Health (0–100), per 10-
point increment
NS NS 1.1 (1.0–1.3) 0.04
*Stepwise multiple logistic regression models were developed for the three outcomes reported. The table presents the final model for each outcome that adjusts
for initial treatment, age, gender, and other independent baseline predictors of outcome (c-statistic ϭ 0.69, predominant symptom improved; 0.78, predominant
symptom much better; 0.74, satisfaction). NS ϭ not (statistically) significant.
†The predominant symptom, either back or leg pain, as indicated by the patient at baseline symptom was categorized as improved if the response was “better,”
“much better,” or “completely gone.” To assess for a more definitive positive treatment outcome, symptom responses were also classified as “much better”
or “completely gone.”
‡Patient considered to be satisfied with their current state if they replied that they were “delighted,” “pleased,” or “mostly satisfied” on a 7-point scale.
§Any self-reported chronic pulmonary disease, heart disease, stroke, cancer, or diabetes.
¶ The no. of positive physical examination findings for a patient, including unilateral strength, sensation, or reflex abnormality (range, 0–3 findings).
**Sum of low back pain frequency and bothersomeness questions in the past week at baseline (score range, 0–12; higher scores indicate worse low back pain).
Figure 1. Time course of symptom and functional status out-
comes. Assessed at initial evaluation and at 3, 6, and 12 months,
and then yearly follow-up for nonsurgical (-F-) and surgical (-E-)
treatment. Mean Ϯ 2 SE. A, Sciatica Frequency Index. B, Modified
Roland score.
931Ten-Year Outcomes of Sciatica • Atlas et al
6. treatment groups and to a similar extent. There was no
change in functional status between 2 and 10 years for
patients initially treated surgically, although there was a
small amount of improvement for nonsurgical patients
(P ϭ 0.2 for the interaction between time and treatment
group).
Lumbar Spine Surgery After Initial Treatment
Among patients initially undergoing surgical treatment,
the 10-year reoperation rate was 25% (n ϭ 64; median
time to reoperation, 24 months). Among patients ini-
tially receiving nonsurgical treatment, the crossover rate
to surgery between 3 months and 10 years was 25% (n ϭ
53; median time to crossover, 24 months). Baseline char-
acteristics and findings were similar for surgical patients
undergoing a reoperation or not, and for nonsurgical
patients having subsequent surgery or not (data not
shown).
10-Year Outcomes According to Actual
Treatment Received
Secondary analyses of treatment effect considered the
actual treatment received at 10-year follow-up for the
138 patients treated completely nonsurgically, and for
the 262 patients treated surgically, including 51 patients
initially in the nonsurgical group who crossed over to
surgical treatment. There were no significant outcome
differences according to actual treatment received at 10-
year follow-up for symptom improvement, satisfaction,
work and disability status, and change in symptom fre-
quency or bother. However, surgically treated patients
had greater improvement in Roland functional status
(10.6 vs. 6.0 point change for surgical and nonsurgical
groups, respectively, P ϭ 0.03).
Ten-year outcomes were also compared according to
the patients’ initial and final treatment status: surgery
with or without a second spine operation (reoperation)
and initial nonsurgical treatment with or without cross-
over to surgical treatment after 3 months (Table 5). Pa-
tients who remained in their initial treatment group
throughout the study, especially those treated surgically,
had better outcomes than those undergoing subsequent
surgery. Surgical patients having a reoperation or non-
surgical patients having subsequent surgery had out-
comes that were inferior to those initially receiving sur-
gical treatment. For example, 51% and 40% of those
having a reoperation or crossing over to subsequent sur-
gery were satisfied with the current state compared with
76% and 61% of surgical or nonsurgical treatment con-
tinuing without subsequent surgery. There was also a
trend for patients undergoing subsequent surgical proce-
dures to have worse disability and work outcomes than
those continuing with their initial treatment, whether
surgical or nonsurgical.
Outcomes of Those Not Completing 10-Year Follow-up
A total of 107 patients did not complete 10-year follow-
up: 56 surgically and 51 nonsurgically treated. Eighty-
six of these 107 patients (80%) returned at least 1 prior
follow-up survey (most recent follow-up: range, 3–108
months; median, 60 months). Outcomes at the most re-
cent follow-up reported by these patients were worse
Figure 2. Time course of satisfaction outcome. Assessed at 3, 6, and
12 months, and then yearly follow-up for nonsurgical (-F-) and sur-
gical (-E-) treatment. Percent satisfied with current state Ϯ 2 SE.
Table 5. 10-Yr Outcomes for Patients Based Upon Initial and Final Treatment Status
10-yr Outcomes
Initial Surgical Treatment Initial Nonsurgical Treatment
No Reoperation Reoperation Crossover to Surgery No Subsequent Surgery
(n ϭ 166) (n ϭ 51) P* (n ϭ 45) P* (n ϭ 138) P*
Predominant symptom, % improved† 71.8 60.8 0.14 48.8 0.006 64.9 0.21
Satisfied with current state, % yes 76.5 51.0 Ͻ0.001 40.0 Ͻ0.001 60.6 0.003
Sciatica Frequency Index, mean change (SD)‡ Ϫ12.5 (7.1) Ϫ9.3 (8.7) 0.008 Ϫ4.5 (7.4) Ͻ0.001 Ϫ5.9 (8.0) 0.02
Roland scale, mean change (SD)‡ Ϫ12.6 (6.9) Ϫ8.4 (7.1) 0.002 Ϫ5.4 (7.6) Ͻ0.001 Ϫ6.0 (7.6) Ͻ0.001
SF-36 general health perceptions, mean
change (SD)§
0.16 (1.2) 0.60 (1.2) 0.02 0.22 (1.1) 0.08 0.26 (1.1) 0.19
If receiving Workers’ Compensation at entry,
current status
(n ϭ 48) (n ϭ 15) (n ϭ 22) (n ϭ 66)
Receiving any disability compensation 12.5 40.0 0.02 27.3 0.14 13.6 0.86
Working 85.4 66.7 0.12 68.2 0.10 77.3 0.28
*Using analysis of variance with Dunnett’s adjustment for multiple comparisons and using surgical with no reoperation group as reference.
†The predominant symptom, either back or leg pain, as rated by the patient at baseline. Symptom severity was reported to be improved if the response was
“better” to “completely gone.”
‡Change is calculated as score at 10 yr minus the score at baseline. Negative values indicate improvement for all variables.
§Assessed using the SF-36 question: “In general, would you say your health is” “excellent” (1) to “poor” (5).
932 Spine • Volume 30 • Number 8 • 2005
7. than those completing 10-year follow-up, but they were
similarly worse for both surgical and nonsurgical pa-
tients. If one includes outcomes from the last available
follow-up survey (3–120 months) for the surgical (n ϭ
266, 97.4%) or nonsurgical (n ϭ 220, 94.0%) cohort,
the comparative results and conclusions are unchanged.
For example, the predominant symptom was improved in
66.4% of surgical and 58.2% of nonsurgical patients (P ϭ
0.06). In multiple regression models examining symptom
improvement and satisfaction with the current state that
included variables for treatment group, time of the last fol-
low-up, and whether the patient died or not, only death was
significantly associated with the outcome (patients lost to
follow-up because of death had better outcomes).
Discussion
Ten-year follow-up in this study was available for 84%
of surviving patients with sciatica due to a herniated
lumbar disc initially treated either surgically or nonsur-
gically. Although patients treated surgically had more
severe symptoms and worse functional status at baseline
than those treated nonsurgically, surgical patients re-
ported better functional status and were more satisfied
with their current state after 10 years. However, a similar
percentage of patients in both groups reported improved
symptoms. Disability and work status were also similar
regardless of initial treatment.
Although the Weber study has been criticized for not
meeting current standards for randomized trials,16
it is
the only randomized comparative trial of surgical versus
nonsurgical treatment for patients with sciatica due to a
lumbar intervertebral disc herniation.8
Our results after
5 years were similar to Weber’s 4-year results.12
At 10
years, Weber reported good results in 63.6% of patients
initially randomized to surgery and 56% of those ini-
tially receiving conservative treatment, a difference that
was not statistically significant. The narrowing of out-
comes between 4 and 10 years represented a small im-
provement for conservatively treated patients and worse
outcomes in surgically treated patients. In our study, fa-
vorable 10-year outcomes were somewhat higher in both
treatment groups (69% and 61%, respectively, among
surgical and nonsurgical patients), but the absolute dif-
ference in good results was nearly identical in the two
studies (see Figure 3 in accompanying manuscript).17
Like Weber’s findings, these overall results did not
achieve statistical significance in unadjusted or adjusted
analyses, even with our larger sample size.
Few other prospective studies have reported long-
term outcomes of discectomy, chemonucleolysis, or con-
servative care for patients with an interververtebral disc
herniation. At 10 years, Gogan reported 77% of patients
initially randomized to chymopapain and 38% of pa-
tients receiving placebo injections were at least moder-
ately improved.18
Other nonrandomized studies com-
paring long-term outcomes of discectomy to other
nonsurgical treatments have found modest differences
favoring surgery.19,20
Although the relative benefit of surgical compared
with nonsurgical treatment was small for improvement
in the patient’s predominant pain symptom, other im-
portant outcomes continued to favor surgery after 10
years, including complete pain relief, back-specific func-
tional status, and satisfaction. Few other comparable
studies have included the broad range of validated out-
come measures used in the Maine Lumbar Spine Study.
Nevertheless, these differences favoring surgical treat-
ment did not translate into better disability and work
outcomes over 10 years. Few patients, irrespective of
initial treatment or Workers’ Compensation status, were
receiving any disability compensation and approxi-
mately 80% were working at 10 years. These results
suggest that specific medical treatments may have less
impact on disability and work status than factors such as
workplace accommodations, job characteristics (tasks,
autonomy, satisfaction, etc.), and other income and local
economic factors.21–24
Among those initially treated surgically, one in four
had at least 1 additional spinal operation over 10 years.
These reoperation rates are generally higher than those
reported in prior studies.19,25–27
For patients initially
treated nonsurgically, another 1 in 4 had subsequent
spine surgery between 3 months and 10 years. Few stud-
ies have examined long-term rates of subsequent surgery
in patients initially managed conservatively.18,19
Al-
though we lack detailed information about the indica-
tions and findings that led to a subsequent operation,
outcomes associated with these procedures were gener-
ally poor. Prior studies have reported conflicting out-
comes from patients undergoing subsequent sur-
gery.28–31
Future research is needed to confirm these
generally poor findings and to perform interventional
trials on patients considering these procedures.
Strengths of our study include prospective, long-term
follow-up in a large percentage of patients from contem-
porary comparison groups treated in community-based
clinical practice using validated outcome measures, all
making it likely that the results are broadly generaliz-
able. The study’s major limitation is its observational,
nonrandomized design.11,12
One cannot be certain that
the differences in outcomes between treatment groups
were exclusively due to surgery, rather than unmeasured
confounders. Important differences at baseline in demo-
graphic, past history, and current symptoms, back-
related disability, and objective findings existed among
those patients treated surgically or nonsurgically. How-
ever, the effect of surgical treatment on the predominant
symptom and satisfaction were similar after adjusting for
other predictors of outcome in regression models. Also,
the overall results are similar to those of Weber’s ran-
domized trial, although both of our treatment groups
had somewhat better outcomes. Finally, although our
follow-up rate is high, these 10-year results likely over-
state the benefit of both surgery and conservative care to
a similar extent based on dropouts in this study appearing
to have worse outcomes than those remaining in the study.
933Ten-Year Outcomes of Sciatica • Atlas et al
8. Although our results support the relative benefit of
surgery for properly selected patients, this does not mean
that nonsurgical treatment should no longer be a recom-
mended initial treatment. Conservative treatment for at
least 4 weeks is recommended for patients with an inter-
vertebral disc herniation without significant neurologic
examination findings.32
After 6 weeks, our results should
not be interpreted as requiring surgery in those without
improvement since many of the conservatively treated
patients in this study had good outcomes. For those with
very bothersome symptoms, surgical treatment can has-
ten recovery and may result in better long-term out-
comes. However, pain outcomes narrow over time, a
sizeable number undergo additional surgery, and work
and disability outcomes are not improved with surgical
treatment. Important questions remain for patients and
physicians about optimal conservative treatment beyond
6 weeks. Patients with persisting symptoms who are re-
luctant to undergo surgery may continue conservative
care knowing that their symptoms will likely improve,
but the magnitude of the improvement may not be as
great as for surgical treatment. It is unclear whether there
is a time window beyond which the relative benefit of
surgery diminishes and thus when conservative treat-
ment should be deemed to have failed.
These results demonstrate how complex it is to inter-
pret outcomes of studies that evaluate the relative impact
of alternative treatments in patients with a lumbar disc
herniation. Patients need to better understand that their
specific symptoms and concerns may determine how rel-
ative treatment benefits and risks should be weighed.
Differences in decision-making depend on whether the
most important outcome is symptoms, function, satisfac-
tion, disability, or work. Efforts are needed to integrate
unbiased information that combines the patient’s perspec-
tive with his or her clinical findings into the clinical deci-
sion-making process.9,33
Additional work is needed to as-
sess whether helping patients and their physicians translate
the complexity of these findings into individualized treat-
ment plan results in improved outcomes of care.34,35
Key Points
● Outcomes of 400 patients with sciatica resulting
from a lumbar disc herniation treated surgically or
nonsurgically were followed over a 10-year period.
● Because treatment was determined in a routine
clinical manner by the patient and the physician,
those surgically treated had more severe symptoms
and worse functional status at baseline.
● Patients initially treated surgically had more
complete relief of leg pain and improved function
and satisfaction compared with patients initially
treated nonsurgically over 10 years.
● However, improvement in the patient’s predom-
inant symptom and work and disability outcomes
were similar regardless of treatment received.
Acknowledgments
The authors thank YuChiao Chang, PhD, for assistance
with statistical analyses and Valerie Soucie for assistance
with managing long-term patient follow-up.
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