NEJM 31 May 2007 Vol 356

All my working life I have been ashamed at the way the NHS treats sciatica. A person – often a mother with young children, or the main family earner – is suddenly incapacitated with nerve root pain and needs to take morphine and diazepam. The weeks go by, and it becomes clear that it won’t get better with mobilisation and physiotherapy, so you wing off a letter to the neurosurgeons, who take a couple of months to see her. There follows a three-month wait for an MRI and then a longer wait for surgery. The months are punctuated by pleas for expedited treatment and better pain relief, and they often result in financial hardship too. Surely any humane system would offer immediate surgery, once the severe sciatica has failed to resolve within 6-12 weeks? I think so, and so did the patients in this Dutch trial; but in fact the long-term outcomes hardly differed between those operated on within weeks and those who had delayed surgery about four months later. The great advantage of early surgery is quicker functional recovery.

I don’t know about you, but I find it hard to visualise the lumbar spine in three dimensions. I occasionally pinch a plastic model from the adjoining consulting room of a partner who was once given it by a drug rep, the better to concoct an explanation for a patient with degenerative spondylolisthesis. Told that their symptoms are due to slippage of the spine, most patients want surgery, which almost always consists of spinal fusion. This made it impossible to conduct a randomised trial of surgical v non-surgical treatment for the condition, because nearly half the patients randomised to non-surgical management insisted on surgery. Those who did so fared better than those who didn’t: so now we know (kind of). And if you would like to spend some more time pondering the structure of the spine in health and disease, there is a useful and well-illustrated focus piece.

About a third of postmenopausal women have osteopenia while only about 6% have osteoporosis (and the same is probably true of men past the age of 60, but nobody seems to be worried). Do we call this “pre-osteoporosis” and march in aggressively with bisphosphonates? Or do we just advise vitamin D and calcium supplements and plenty of exercise? Almost certainly the latter, according to this clinical discussion piece.