Comparative Clinical Effectiveness of Management Strategies for Sciatica: Systematic Review and Network Meta-Analyses

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 (NIHR) HTA programme; there are no potential conflict of interests. Results Of 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 significant improvement following disc surgery, epidural injections, non-opioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy and exercise therapy were significantly inferior to epidural injections or surgery. For pain reduction 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, non-opioids, and opioids, or radiofrequency treatment. Opioids, education/advice alone, bed rest, and percutaneous discectomy and radiofrequency treatment 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 non-opioid 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 support 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

Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review

PURPOSE: To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach. MATERIAL AND METHODS: This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics. RESULTS: A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5 %). The interlaminar access route was used in 44 of 91 studies (48.4 %), the transforaminal in 37 of 91 studies (40.7 %), and the caudal pathway in 26 of 91 studies (28.6 %). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0 %), steroids (all studies) and image guidance (71 of 91 studies, 78 %). CONCLUSIONS: The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years