MANIPULATION OR MICRODISKECTOMY FOR SCIATICA? APROSPECTIVE RANDOMIZED CLINICAL STUDY Gordon McMorland, DC, a Esther Suter, PhD, b Steve Casha, MD, PhD, FRCSC, c Stephan J. du Plessis, MD, c and R. John Hurlbert, MD, PhD, FRCSC, FACS c ABSTRACT Objective: The purpose of this study was to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH). Methods: One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. Forty consecutive consenting patients who met inclusion criteria (patients must have 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. Results: Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measures. After 1 year, follow-up intent-to-treat analysis did not reveal a difference in outcome based on the original treatment received. However, 3 patients crossed over from surgery to spinal manipulation and failed to gain further improvement. Eight patients crossed from spinal manipulation to surgery and improved to the same degree as their primary surgical counterparts. Conclusions: Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted. (J Manipulative Physiol Ther 2010;33:576-584) Key Indexing Terms: Manipulation, Spinal; Disk, Herniated; Sciatica; Diskectomy, Percutaneous; Chiropractic INTRODUCTION The prevalence of sciatica caused by lumbar disk herniation (LDH) has been estimated to have a lifetime incidence of between 2% and 40%. 1 In a large population sample, a diagnosis of lumbar disk herniation with sciatica was present in 5.1% of men and 3.7% of women older than 30 years. 2 Physical workload factors appear related to the onset of sciatica, whereas psychosocial factors, heavy labor, and obesity seem related to adverse outcome. 3,4 Initial intervention for the treatment of patients with sciatica is usually nonoperative given the spontaneous recovery seen in most patients. 5 Nonoperative management has been demonstrated to be beneficial in more than 50% of patients with sciatica 4,6 ; however, there are no established guide- lines for appropriate medical management strategies. A variety of regimens have been recommended, but recent guidelines have failed to show that any nonoperative treatment approaches have been subjected to high-quality clinical trials. 7,8 Those patients failing “conservative care” are frequently recommended for surgical assessment. Elective lumbar diskectomy is one of the most commonly performed surgical procedures in the United States, now exceeding 250,000 cases per year. 9-13 Studies comparing surgical management of LDH to different forms of conservative treatment tend to favor surgery with respect to short-term outcome. 10-14 However, there are less striking differences observed in long-term follow-up of 1 year or more. 15-17 Improvement in the patient's predominant symptom, return to work, and persisting disability tend to be similar regardless of treatment received. The role of spinal manipulation in nonoperative care of sciatica is unestablished. Most studies define conventional nonoperative care as exercise, analgesics, and/or epidural a Chiropractor, National Spine Care, Calgary, Alberta, Canada. b Senior Research and Evaluation Consultant, Health Systems and Workforce Research Unit, Alberta Health Services, Calgary, Alberta, Canada. c Spinal Neurosurgeon, University of Calgary Spine Program and Division of Neurosurgery, Foothills Hospital and Medical Centre, Calgary, Alberta, Canada. Submit requests for reprints to: Gordon McMorland, DC, National Spine Care, #300, 301 14th Street N.W., Calgary, AB, Canada T2N 2A1 (e-mail: gmcmorland@nationalspinecare.com). Paper submitted December 30, 2009; in revised form March 17, 2010; accepted June 8, 2010. 0161-4754/$36.00 Copyright © 2010 by National University of Health Sciences. doi:10.1016/j.jmpt.2010.08.013 576