[Current therapeutic options in sciatica caused by disk herniation].

Abstract

The results of reliable therapeutic trials, experimental studies showing that compression is not the only mechanism of nerve root alterations, and mainly, the favorable spontaneous outcome of 95% of the sciatica command a critical approach of all the treatments of sciatica by disc herniation. A disc herniation can be observed in 20% of asymptomatic population. Except neurological complications requiring an early surgical decompression, the management of sciatica should begin by a 2 to 3 months period of medical treatment including analgesic drugs or NSAID, a 8 to 10 day bed rest, epidural corticosteroid injections validated in controlled studies, and a lumbar brace during 4 to 6 weeks. The reference treatment of disc herniation in patients whose conservative treatment failed is conventional surgery. The average rate of failure following decompressive surgery is 15 to 20% and the need for further surgery ranges from 5 to 15%. The main cause of failure is the absence of true compressive herniation before the initial operation. Microscope removal of disc herniation does not lead to better results than the standard procedure and there is a 20% risk of recurrence when only the herniated fragment is removed. The success rate of chemonucleolysis approaches 65-70% but the procedure need a strict care to prevent severe complications. Manual percutaneous discectomy, whatever the procedure are supported only by uncontrolled studies. The only randomized trial in automated percutaneous discectomy versus chemonucleolysis reported a 37% success rate with a one-year follow-up. Benefit/risk ratio should always be considered before every treatment of sciatica.