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【medical-news】手术更能有效治疗坐骨神经痛么？
Is surgery better in treating a slipped disk?
A major study intended to determine if sciatica, a burning sensation in the leg caused by a slipped disk, can best be treated by surgery or nonsurgical medical treatment has found that patients receiving either procedure do very well after two years with a slight advantage for surgical patients.
The study, supported by the National Institutes of Health, was intended to help settle the long-standing controversy over the effectiveness of spinal surgery to repair a slipped disk compared to conservative therapy that includes special exercises and anti-inflammatory drugs.
But the results, reported in Wednesday's issue of the Journal of the American Medical Association, were somewhat inconclusive primarily because attempts to randomly assign patients into two distinct groups broke down. Forty percent of the 232 patients who were to have disk surgery changed their mind and opted for nonsurgical therapy, while 45 percent of the 240 patients assigned to nonsurgical care decided to have surgery. The study was conducted in 13 spine clinics in 11 states.
"We can't say which treatment is better," said Dr. David R. Flum of the University of Washington, who commented on the study in a JAMA editorial. "We can say that people who choose their intervention seemed to be choosing wisely because both groups got better.
"Of course it remains to be seen whether or not the people who chose surgery, had they not chosen surgery, would they have done just as well? That's really the question that everybody wants to know."
Despite the surprising crossover problem, the study had several important findings, said the study's lead author, Dr. James N. Weinstein of Dartmouth Medical School.
"This study for the first time showed very significant improvement in the patients who ended up with nonoperative treatment," he said. "On the other hand, if they had to engage in a surgical option they also did quite well and there weren't a lot of side effects. We also learned that patients don't get a lot worse in either treatment."
An estimated 12 million Americans suffer from degenerative disk disease. Of the more than 1 million who undergo surgery to repair herniated disks each year, about 25 percent suffer from sciatica. Surgery costs approximately $10,000 and can be done on an outpatient basis.
Disks made of cartilage separate and cushion the spine's vertebra. When these disks rupture, usually through wear and tear, they can bulge inward, pressing on nerves in the spinal column, causing pain or partial weakness.
Trying to find an answer to the surgery vs. nonsurgery debate for herniated disks is important, Weinstein said, because the number of spinal operations has been increasing and the rate of these surgeries can vary by as much as 15-fold in different regions of the country.
The study found that surgery quickly relieves disabling symptoms in patients with sciatica when compared with nonsurgical care. Surgery patients were often able to resume normal activities in a matter of weeks, while those not being operated on usually took several months or more to feel as good. But after two years both groups appeared to do equally well.
"Surgery for sciatica looks like it is very effective as opposed to surgery for back pain, which does not look like it is," said Dr. Eugene Carragee of Stanford University Medical Center, who wrote an accompanying JAMA editorial.
"What that's telling us is that the natural history of having sciatica is that it will eventually get better in most people, but it can take a long, long time," he said. "By six weeks after surgery those people are very close to normal in pain, function and other parameters."
The study also found that severely damaged disks do not appear to pose a risk of paralysis or other catastrophic event if not surgically corrected. Many surgeons advise surgery out of concern that any sudden twisting movement might further damage a ruptured disk.
For patients in whom sciatica causes intolerable pain or makes them unable to work or take care of a family, then surgery will make them feel better quickly, Carragee said. And for people who want to avoid surgery, they can do so knowing that there is little risk of making the problem worse, he said.
"No one should be frightened into having the operation done because they're worried that something terrible will happen to them if they don't have it done," Carragee said. "A person's preference can be justified either way."
Weinstein said the study shows that sciatica patients have a choice. "The traditional thing that doctors use to sign patients up for surgery is called 'informed consent.' The doctor says 'OK, you have a herniated disk, we're going to operate, here are the risks and benefits, please sign this piece of paper.'"
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作者:admin@医学,生命科学 2011-06-16 17:14
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