The smallest worthwhile effect of surgery versus non-surgical treatments for sciatica: a benefit-harm trade-off study

Abstract

QUESTION: What is the smallest worthwhile (SWE) effect of discectomy compared with non-surgical treatments amongst people with sciatica? DESIGN: Benefit-harm trade-off study. PARTICIPANTS: People with sciatica of any duration living in Australia and recruited through social media. OUTCOME: The outcome of interest was leg pain intensity. Participants were asked to nominate the additional percentage reduction in leg pain from discectomy--above the reduction anticipated from non-surgical treatments--that would make discectomy worthwhile for them. The SWE was estimated as the median (IQR) of the smallest percentage reduction in leg pain with discectomy (compared with non-surgical treatment) that participants considered worthwhile. The SWE was estimated for the overall sample and those with acute (? 6 weeks), subacute (> 6 to 12 weeks) and chronic (> 12 weeks) sciatica, and investigated factors associated with the SWE. RESULTS: Two hundred participants with a mean age of 59 years (SD 12) were included. The SWE was estimated to be an additional 15% (IQR 10 to 40) reduction in leg pain with discectomy, beyond any reduction in leg pain achieved by non-surgical treatments. Dissatisfaction with previous non-surgical treatments and low pain self-efficacy were associated with smaller SWE estimates. CONCLUSION: People with sciatica would require discectomy to provide an additional 15% reduction in their leg pain beyond the expected 50% improvement in leg pain from non-surgical treatments in the short term to consider discectomy worthwhile. These results can inform the interpretation of the effects of discectomy in randomised trials and meta-analysis from the perspective of consumers.