Comparative Clinical Effectiveness of Management Strategies for Sciatica

Many treatment approaches for sciatica exist. Systematic reviews conducted in the past have not compared all these strategies together. The authors therefore conducted this review to compare the clinical effectiveness of various treatment strategies for sciatica simultaneously. A systematic review and network meta-analysis was conducted. They searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research (NIHR) HTA programme; there are no potential conflict of interests. They found 122 relevant studies; 90 were randomised controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically substantial improvement after disc surgery, epidural injections, non-opioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy and exercise therapy were significantly inferior to epidural injections or surgery. With pain as the outcome, epidural injections, and biological agents were significantly superior to inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, non-opioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were not as good as most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

In conclusion the authors say that this is the first time many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis, and that this approach has provided new data to aid shared decision-making. Their findings support the effectiveness of non-opioid medication, epidural injections and disc surgery. They also indicate that spinal manipulation, acupuncture, and experimental treatments such as anti-inflammatory biological agents, may be considered. Their findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy or traction. They do add however that the problem how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway is still an important problem to solve.