title: Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis.
abstract: Previous reviews have compared surgical to non-surgical management of sciatica, but have overlooked the specific comparison between surgery and physical activity-based interventions.
  
  
  
  Systematic review using MEDLINE, CINAHL, Embase and PEDro databases was conducted. Randomised controlled trials comparing surgery to physical activity, where patients were experiencing the three most common causes of sciatica-disc herniation, spondylolisthesis and spinal stenosis. Two independent reviewers extracted pain and disability data (converted to a common 0-100 scale) and assessed methodological quality using the PEDro scale. The size of the effects was estimated for each outcome at three different time points, with a random effects model adopted and the GRADE approach used in summary conclusions.
  
  
  
  Twelve trials were included. In the short term, surgery provided better outcomes than physical activity for disc herniation: disability [WMD -9.00 (95 % CI -13.73, -4.27)], leg pain [WMD -16.01 (95 % CI -23.00, -9.02)] and back pain [WMD -12.44 (95 % CI -17.76, -7.09)]; for spondylolisthesis: disability [WMD -14.60 (95 % CI -17.12, -12.08)], leg pain [WMD -35.00 (95 % CI -39.66, -30.34)] and back pain [WMD -20.00 (95 % CI -24.66, -15.34)] and spinal stenosis: disability [WMD -11.39 (95 % CI -17.31, -5.46)], leg pain [WMD, -27.17 (95 % CI -35.87, -18.46)] and back pain [WMD -20.80 (95 % CI -25.15, -16.44)]. Long-term and greater than 2-year post-randomisation results favoured surgery for spondylolisthesis and stenosis, although the size of the effects reduced with time. For disc herniation, no significant effect was shown for leg and back pain comparing surgery to physical activity.
  
  
  
  There are indications that surgery is superior to physical activity-based interventions in reducing pain and disability for disc herniation at short-term follow-up only; but high-quality evidence in this field is lacking (GRADE). For spondylolisthesis and spinal stenosis, surgery is superior to physical activity up to greater than 2 years follow-up. Results should guide clinicians and patients when facing the difficult decision of having surgery or engaging in active care interventions. PROSPERO registration number : CRD42013005746.
authors.affiliation: Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia. mfer4234@uni.sydney.edu.au.
authors.forename: Matthew
authors.initials: M
authors.lastname: Fernandez
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, 321 Kent Street, Sydney, NSW, 2000, Australia.|The Institute of Bone and Joint Research, Sydney Medical School, University of Sydney, Sydney, Australia.
authors.forename: Manuela L
authors.initials: ML
authors.lastname: Ferreira
authors.affiliation: Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia.
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Refshauge
authors.affiliation: Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.|Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M, Denmark.
authors.forename: Jan
authors.initials: J
authors.lastname: Hartvigsen
authors.affiliation: Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia.
authors.forename: Isabela R C
authors.initials: IR
authors.lastname: Silva
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, 321 Kent Street, Sydney, NSW, 2000, Australia.
authors.forename: Chris G
authors.initials: CG
authors.lastname: Maher
authors.affiliation: Department of General Practice, Erasmus University Medical Centre, P.O. Box 2040, 3000, Rotterdam, The Netherlands.
authors.forename: Bart W
authors.initials: BW
authors.lastname: Koes
authors.affiliation: Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, Sydney, NSW, 2141, Australia.
authors.forename: Paulo H
authors.initials: PH
authors.lastname: Ferreira
mesh_terms: D004185:Disability Evaluation; D005081:Exercise Therapy; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000150:complications / Q000628:therapy; D019635:Neurosurgical Procedures; D019637:Orthopedic Procedures; D012585:Sciatica / Q000209:etiology / Q000628:therapy*; D013130:Spinal Stenosis / Q000150:complications / Q000628:therapy; D013168:Spondylolisthesis / Q000150:complications / Q000628:therapy
keywords: Meta-analysis; Physical activity; Sciatica; Surgery; Systematic review