title: Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses.
abstract: BACKGROUND
  There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.
  
  
  OBJECTIVE
  To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.
  
  
  METHODS
  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.
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP. Electronic address: lewisr17@cardiff.ac.UK.
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Lewis
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP; North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, UK LL57 2PZ.
authors.forename: Nefyn H
authors.initials: NH
authors.lastname: Williams
authors.affiliation: Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, UK LE1 6TP.
authors.forename: Alex J
authors.initials: AJ
authors.lastname: Sutton
authors.affiliation: Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH.
authors.forename: Kim
authors.initials: K
authors.lastname: Burton
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
authors.forename: Nafees Ud
authors.initials: NU
authors.lastname: Din
authors.affiliation: Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, UK S5 7AU.
authors.forename: Hosam E
authors.initials: HE
authors.lastname: Matar
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
authors.forename: Maggie
authors.initials: M
authors.lastname: Hendry
authors.affiliation: School of Human and Health Sciences, Swansea University, Singleton Park, Swansea, UK SA2 8PP.
authors.forename: Ceri J
authors.initials: CJ
authors.lastname: Phillips
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
authors.forename: Sadia
authors.initials: S
authors.lastname: Nafees
authors.affiliation: Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH.
authors.forename: Deborah
authors.initials: D
authors.lastname: Fitzsimmons
authors.affiliation: Green Oak, Dolydd Terrace, Betws-Y-Coed, UK LL24 0BU.
authors.forename: Ian
authors.initials: I
authors.lastname: Rickard
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
authors.forename: Clare
authors.initials: C
authors.lastname: Wilkinson
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use*; D001510:Bed Rest; D019468:Disease Management; D017587:Diskectomy, Percutaneous; D005081:Exercise Therapy; D006801:Humans; D007268:Injections, Epidural; D020393:Manipulation, Spinal; D012585:Sciatica / Q000628:therapy*; D014143:Traction; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid
keywords: Clinical effectiveness; Intervertebral disc herniation; Mixed treatment comparisons; Sciatica; Systematic review; Treatment strategies