mri 1 year after sciatica

NEJM with recent study of sciatica and MRI (see low back pain mri after 1 yr unhelpful nejm 2013 in dropbox).  followup on previously reported study, the Leiden-The Hague spine intervention prognostic study group (see lbp sciatica surgery vs med nejm 2007in dropbox), which assessed 283 people with sciatica for 6-12 weeks and MRI showing nerve root impingement correlating with sx, randomized pts to early surgery vs medical management, finding that improvement was faster with early surgery, but no diff in results after 1 year.  they then did repeat MRI after 1 year, when postop fibrosis should have stabilized, and compared MRI findings to clinical outcomes.  results:
   
-84% overall had favorable clinical outcomes (complete or near complete disappearance of sx at one year), with 85% of those with disc herniation had a favorable outcome and 83% without disc herniation had a favorable outcome (ie, no difference)
-disc herniation was found in 35% of pts with favorable outcome and 33% with unfavorable outcome (either persistent sx or re-emergence of sx). also no difference in those read as having nerve root compression (24% vs 26%)
 
so, sciatica really common (13-40% lifetime incidence), mostly goes away on its own within 8 weeks, but persists in 15-20% either as recurring or persistent sx.  one year outcome same with or without surgery, though faster with surgery. but, 1/3 of those assigned to nonsurgical management in the initial leiden study crossed over to have surgery after 19 weeks. but, overall after one year 95% had favorable outcome (this number is cited in the original report, though above study reported 84%). other studies cited in the article came to similar conclusions about the utillity of subsequent MRIs.
 
 bottom line from this article, as noted by them "patients asking for reimaging because of persistent or recurrent sx should be informed about the difficulty in MRI interpretation".  i would add that we as clinicians should also be hesitant to repeat the MRI.  as a related side note, MRI has been shown in several studies to give too much information -- eg, mri's done in people without a history of low back pain (yes, they do exist) can show significant "abnormalities". one early study, for example see lbp mri in pts without pain nejm 1994 in dropbox, found that 52% of 98 patients had abnormal disc bulges, 27% with disc protrusion.  there was also a more recent study with even worse looking mri's, though i don't have it on-hand now.

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