Spinemathema podcast · Episode 4 · About 8 minutes · October 2026

Episodes are narrated using an AI model of Mr Sadek’s own voice, from scripts he has written and approved.

Read the full article with references: Early Surgery or Waiting for Sciatica? What the Leiden Sciatica Trial Found

Transcript

Hello and welcome to the Spinemathema podcast. I’m Ahmed Sadek, a neurosurgeon. In this episode I’m looking at one landmark spine trial and explaining, in plain English, what it means for patients.

Today’s trial comes from the Netherlands. It’s usually called the Sciatica Trial, and it was run by a group of doctors from Leiden and The Hague. The main results were published in the New England Journal of Medicine in two thousand and seven, and the team followed their patients up for two years and then five years.

First, a quick reminder about sciatica. Sciatica is pain that travels from the lower back down the leg, often with tingling or numbness. The most common cause is a slipped disc. Part of the cushion between two bones of the spine bulges out and presses on a nerve. Many people get better on their own, but the pain can be severe, and it can stop people working, sleeping and getting on with life. For those who don’t settle, an operation called a discectomy removes the piece of disc that’s pressing on the nerve.

At the time, disc surgery was often done when sciatica hadn’t settled within about six weeks. But nobody really knew the best time to operate. So this trial asked a slightly different question from most. It wasn’t really surgery or no surgery. It was this. Should we operate early? Or should we carry on with non surgical treatment for longer, and only operate if we need to?

Here’s how it worked. The trial took place in nine Dutch hospitals. It included adults aged eighteen to sixty five who had had severe sciatica for six to twelve weeks, with a slipped disc confirmed on a magnetic resonance imaging scan, or MRI. Two hundred and eighty three people took part, and a computer decided which group each person went into.

One hundred and forty one people were assigned to early surgery. That was a microdiscectomy, where the surgeon removes the disc fragment through a small opening using magnification. In this group, one hundred and twenty five people, or eighty nine percent, had the operation, on average just over two weeks after joining the trial.

The other one hundred and forty two people were assigned to what the researchers called prolonged conservative care. That meant about six more months of non surgical treatment, guided by their family doctor and mainly aimed at getting back to normal daily activities. If their symptoms didn’t improve, they could have surgery.

The patients were told at the start that the trial was comparing two strategies for the timing of treatment, not surgery against no surgery. The researchers measured disability with a questionnaire, leg pain on a scale from nought to one hundred, and each person’s own sense of whether they had recovered.

So what did they find? The first finding was speed. Leg pain eased faster in the early surgery group, and those patients felt they had recovered sooner. To give you a sense of it, at eight weeks the average leg pain score was about ten out of one hundred in the early surgery group, and about twenty eight in the conservative group. That’s a real difference, and it matters if you’re in a lot of pain.

But the second finding is just as important. Over the first year, there was no significant difference in disability between the two groups. And after one year, ninety five percent of people in both groups reported that they had recovered. At two years, the groups were still similar, and the early advantage in leg pain had stopped being significant from about six months. At five years, with just over four in five of the original patients still taking part, there were still no significant differences between the groups.

Now, what about the people in the conservative group? How many of them ended up having an operation? By one year, thirty nine percent had had surgery, on average about nineteen weeks after joining. By two years it was forty four percent, and by five years forty six percent. Put the other way round, more than half of them never needed an operation. And here’s something I find interesting. Sixteen people who were assigned to early surgery got better before their operation and never had surgery at all during those five years.

I should also be honest that not everyone recovered fully. At two years, one in five patients reported an unsatisfactory outcome. At five years, it was twenty one percent, and that was almost exactly the same in both groups. People who were over forty, who had very severe leg pain at the start, or who scored higher on a questionnaire about the emotional side of their pain, were more likely to have a less good result. And a small number in both groups needed a second disc operation within five years.

So what are the limitations? The biggest one is switching. Nearly half the conservative group eventually had surgery, and some of the surgery group didn’t. That’s realistic, but it means the trial compares two strategies rather than surgery against no surgery. There was no blinding. Patients knew which group they were in, and they were the ones reporting their pain and recovery. By five years, almost one in five patients had dropped out of follow up. The trial only included adults up to sixty five, with six to twelve weeks of symptoms, so it may not apply to older people or to sciatica that has gone on much longer. And it was published in two thousand and seven, in a Dutch health system where family doctors guided the conservative care. Treatment has continued to develop since then.

If you’ve listened to our episode on the American SPORT trial, you’ll notice that the two trials reached broadly similar conclusions.

So what does this mean for you? If you have sciatica from a slipped disc, you’ve had it for a couple of months, and you have no warning signs, this trial suggests there isn’t one right answer. Early surgery is likely to ease your leg pain sooner. That can matter a great deal if the pain is severe, or if it’s stopping you working. On the other hand, carrying on with good non surgical care, such as physiotherapy, pain relief and sometimes a nerve root injection, gives you a better than even chance of avoiding an operation. And if you do need surgery later, the evidence suggests your result by one year is likely to be similar.

That’s why I see this as a shared decision. It depends on how bad your pain is, how it’s affecting your life, and how you feel about surgery and its risks.

One important safety point. If you develop numbness around your bottom or genitals, new problems controlling your bladder or bowels, or leg weakness that’s getting rapidly worse, please seek urgent medical help. These can be signs of cauda equina syndrome, which needs emergency assessment.

Thank you for listening. Please remember that this podcast is general information and not a substitute for advice about your own situation, so do speak to your own doctor. You’ll find the full article, the diagrams and all the references at spinemathema dot com. And if you found this helpful, please subscribe to the Spinemathema channel on YouTube.

This podcast is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.