Surgery for lumbar radiculopathy/ sciatica

Status: Decision completed

Policy context

Numerous surgical and nonsurgical approaches to the management of lumbar radiculopathy have been studied and are routinely used within current clinical practice. In addition to standard surgical techniques (e.g., laminectomy, discectomy), minimally invasive surgical techniques that use percutaneous, endoscopic, or laser-assisted approaches are now available. 

Primary criteria ranking

  • Safety = Medium
  • Efficacy = High
  • Cost = High
Documents

Assessment timeline

  • Draft key questions published: November 14, 2017
  • Public comment period: November 14 to 27, 2017
  • Final key questions published: December 21, 2017
  • Draft report published: February 22, 2018
  • Public comment period: February 22 to March 23, 2018
  • Final report published: April 18, 2018
  • HTCC public meeting: May 18, 2018

Background

Radiculopathy is a clinical syndrome characterized by pain, motor weakness, and sensory disturbances in a myotomal or dermatomal distribution. When radicular symptoms are in the low back and legs, this condition is referred to as lumbar radiculopathy or sciatica. Nerve root compression is a common cause of radiculopathy and various pathological processes may be responsible, but most often it results from disc herniation or spondylosis (i.e., degenerative joint and disc disease). Both processes can cause stenosis of the lateral recesses or neural foramina and resulting spinal nerve root compression. Degenerative changes can also produce spondylolisthesis, central spinal canal stenosis, and facet joint hypertrophy, which may be associated with nonradicular low back pain. Less common etiologies of radiculopathy include infection, inflammation, neoplasm, vascular disease, and congenital abnormalities. Radiculopathy is a clinical diagnosis because spinal nerve root compression identified with imaging may not always be symptomatic. Thus, correlation of symptoms and physical exam with imaging is usually used to diagnose radiculopathy, with electromyography reserved for selected patients. The lifetime prevalence of lumbar radiculopathy is 3 to 5%.

Lumbar radiculopathy is a heterogeneous condition that may present acutely (as in the case of an acute disc herniation with chemical radiculitis) or more insidiously (as in the case of spondylosis). Further, radiculopathy may present only with pain or with varying degrees of sensory disturbance or motor weakness. The objective of treatment for radiculopathy is symptom relief. If pain or neurologic symptoms are severe or nonresponsive to conservative measures, then surgical treatment of the underlying causative mechanism may be warranted.