Comparative clinical effectiveness of management strategies for sciatica: Systematic review and network meta-analyses

Ruth Lewis, Nefyn Williams, Alex Sutton, Anthony Burton, Nafees Ud Din, Hosam E. Matar, Maggie Hendry, Ceri J. Phillips, Sadia Nafees, Deborah Fitzsimmons, Ian Rickard, Clare Wilkinson

Research output: Contribution to journalArticle

35 Citations (Scopus)

Abstract

Background:
There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

Purpose:
To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

Study design:
Systematic review and network meta-analysis.

Methods:
We 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 Health Technology Assessment program; there are no potential conflict of interests.

Results:
We identified 122 relevant studies; 90 were randomized 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 significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

Conclusions:
For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.
LanguageEnglish
Pages1461-1477
Number of pages17
JournalSpine Journal
Volume15
Issue number6
Early online date3 Oct 2013
DOIs
Publication statusPublished - 1 Jun 2015

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Sciatica
Epidural Injections
Percutaneous Diskectomy
Bed Rest
Biological Factors
Opioid Analgesics
Exercise Therapy
Traction
Therapeutics
Pain
Randomized Controlled Trials
Acupuncture Analgesia
Acupuncture Therapy
Spinal Manipulation
Education
Conflict of Interest
Biomedical Technology Assessment
Network Meta-Analysis
National Institutes of Health (U.S.)
Bibliography

Cite this

Lewis, Ruth ; Williams, Nefyn ; Sutton, Alex ; Burton, Anthony ; Ud Din, Nafees ; Matar, Hosam E. ; Hendry, Maggie ; Phillips, Ceri J. ; Nafees, Sadia ; Fitzsimmons, Deborah ; Rickard, Ian ; Wilkinson, Clare. / Comparative clinical effectiveness of management strategies for sciatica : Systematic review and network meta-analyses. In: Spine Journal. 2015 ; Vol. 15, No. 6. pp. 1461-1477.
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Lewis, R, Williams, N, Sutton, A, Burton, A, Ud Din, N, Matar, HE, Hendry, M, Phillips, CJ, Nafees, S, Fitzsimmons, D, Rickard, I & Wilkinson, C 2015, 'Comparative clinical effectiveness of management strategies for sciatica: Systematic review and network meta-analyses', Spine Journal, vol. 15, no. 6, pp. 1461-1477. https://doi.org/10.1016/j.spinee.2013.08.049

Comparative clinical effectiveness of management strategies for sciatica : Systematic review and network meta-analyses. / Lewis, Ruth; Williams, Nefyn; Sutton, Alex; Burton, Anthony; Ud Din, Nafees; Matar, Hosam E.; Hendry, Maggie; Phillips, Ceri J.; Nafees, Sadia; Fitzsimmons, Deborah; Rickard, Ian; Wilkinson, Clare.

In: Spine Journal, Vol. 15, No. 6, 01.06.2015, p. 1461-1477.

Research output: Contribution to journalArticle

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T1 - Comparative clinical effectiveness of management strategies for sciatica

T2 - Spine Journal

AU - Lewis, Ruth

AU - Williams, Nefyn

AU - Sutton, Alex

AU - Burton, Anthony

AU - Ud Din, Nafees

AU - Matar, Hosam E.

AU - Hendry, Maggie

AU - Phillips, Ceri J.

AU - Nafees, Sadia

AU - Fitzsimmons, Deborah

AU - Rickard, Ian

AU - Wilkinson, Clare

PY - 2015/6/1

Y1 - 2015/6/1

N2 - Background:There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.Purpose:To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.Study design:Systematic review and network meta-analysis.Methods:We 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 Health Technology Assessment program; there are no potential conflict of interests.Results:We identified 122 relevant studies; 90 were randomized 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 significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.Conclusions:For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

AB - Background:There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.Purpose:To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.Study design:Systematic review and network meta-analysis.Methods:We 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 Health Technology Assessment program; there are no potential conflict of interests.Results:We identified 122 relevant studies; 90 were randomized 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 significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.Conclusions:For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

KW - systematic review

KW - Sciatica

KW - intervertebral disc herniation

KW - mixed treatment comparisons

KW - clinical effectiveness

KW - treatment strategies

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