STUDY DESIGN: Retrospective study. PURPOSE: To evaluate the return-to-work rate and long-term outcomes of delayed versus early surgery for back pain and sciatica among railway workers. OVERVIEW OF LITERATURE: The timing of conservative versus surgical treatment and their long-term clinical effectiveness remain controversial. To our knowledge, there are no studies on the long-term postoperative outcomes and risk factors for unsatisfactory long-term clinical outcomes after conservative and surgical treatment of lumbar degenerative diseases in railway workers. METHODS: We identified patients with persistent back pain and sciatica due to lumbar degeneration at L4-L5 or L5-S1 treated between 2010 and 2020. Two groups of patients were identified: The Delayed group (n=692) initially refused operative care despite 6-12 weeks of non-operative care, and the Early group (n=1,687) underwent surgery immediately after routine (6-12 weeks) non-operative care was unsuccessful. Perioperative clinical data and return-to-work rates were obtained before surgery and at a minimum of 40 months postoperatively. Factors associated with unfavorable outcomes were also identified. RESULTS: At baseline, the two groups had comparable clinical data, demographics, and workload intensity. There were significantly better clinical results, fewer complications, and a higher frequency of return to work in the Early group than in the Delayed group (p<0.05); 15.3% (209) and 25.7% (147) of the patients in the Early and Delayed groups, respectively, had unsatisfactory long-term clinical outcomes. Specific factors associated with unsatisfactory long-term clinical outcomes in the delayed surgery group were male sex, diabetes mellitus, lower extremity pain Visual Analog Scale >40 mm, Oswestry Disability Index >48%, physical component score <18 points, preoperative use of narcotic analgesics, and light-to-medium and heavy-to-very heavy preoperative workload. CONCLUSIONS: In this single-center study involving railway workers with lumbar degenerative back pain and sciatica, early surgery was superior to delayed surgery in terms of pain intensity, functional status, quality of life, return-to-work rate, and reoperation rate at the long-term follow-up. Further prospective studies with larger sample sizes are required to clarify this association.