Re: Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials
Dear Editor,
We read with interest the recent systematic review and meta-analysis from Liu and colleagues published in the BMJ.4 Although the authors are to be congratulated for collating the data from such a large number of patients in a commonly encountered pathology, we are of the view that their conclusions are not supported by data provided by high quality randomized controlled trials (RCT) and may represent an over-reliance on the pooled results of studies of variable quality.3
In particular, we wish to comment on the absence of a recommendation to consider transforaminal epidural steroid injection (TFESI) as an alternative to early surgery or continued conservative management. The NERVES trial was a multi-centre RCT of microdiscectomy vs. TFESI in the management of sciatica due to a herniated lumbar disc published by our group.5 This trial demonstrated no difference in relief of back and leg pain when surgery and the less invasive TFESI were compared, and the majority of patients randomised to the TFESI arm did not require surgical intervention during the follow-up period. Furthermore, all of the treatment associated serious adverse effects were observed in the surgical arm. We found it curious, therefore, that the authors did not advocate for the use of TFESI as an early intervention for this pathology in view of the demonstrable evidence of efficacy. More broadly, the majority of studies included in this systematic review and meta-analysis were found to be at high or unknown risk of bias (Supplemental Table 11) and therefore pooling their results with a view to making definitive treatment recommendations is problematic.
Moreover, the assertion from the authors that “No trials reported outcomes for quality of life and treatment satisfaction.” is incorrect; NERVES reported patient satisfaction outcomes for treatment satisfaction using a previously validated Likert scale and quality of life was assessed using the widely applied EuroQol -5D-3L questionnaire.1,2,5
In summary, research from our group has demonstrated that the use of TFESI in patients with sciatica of 6 weeks-12 months duration was an effective intervention that obviated the requirement for surgical intervention in ~60% of those patients that received it.5 We strongly recommend that this intervention be considered as an initial alternative to surgery in patients with symptomatic posterolateral disc herniations without significant associated neurological deficits. Finally, the use of meta-analyses of poorly performed studies to draw conclusions on optimal treatment modalities when well-designed RCTs addressing the question are available is not an approach we consider to be advisable.
References:
1. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy 16:199-208, 1990
2. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, et al: Outcome measures for low back pain research. A proposal for standardized use. Spine (Phila Pa 1976) 23:2003-2013, 1998
3. Jensen RK, Kongsted A, Kjaer P, Koes B: Diagnosis and treatment of sciatica. Bmj 367:l6273, 2019
4. Liu C, Ferreira GE, Abdel Shaheed C, Chen Q, Harris IA, Bailey CS, et al: Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ 381:e070730, 2023
5. Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, et al: Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluation. Lancet Rheumatol 3:e347-e356, 2021
Rapid Response:
Re: Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials
Dear Editor,
We read with interest the recent systematic review and meta-analysis from Liu and colleagues published in the BMJ.4 Although the authors are to be congratulated for collating the data from such a large number of patients in a commonly encountered pathology, we are of the view that their conclusions are not supported by data provided by high quality randomized controlled trials (RCT) and may represent an over-reliance on the pooled results of studies of variable quality.3
In particular, we wish to comment on the absence of a recommendation to consider transforaminal epidural steroid injection (TFESI) as an alternative to early surgery or continued conservative management. The NERVES trial was a multi-centre RCT of microdiscectomy vs. TFESI in the management of sciatica due to a herniated lumbar disc published by our group.5 This trial demonstrated no difference in relief of back and leg pain when surgery and the less invasive TFESI were compared, and the majority of patients randomised to the TFESI arm did not require surgical intervention during the follow-up period. Furthermore, all of the treatment associated serious adverse effects were observed in the surgical arm. We found it curious, therefore, that the authors did not advocate for the use of TFESI as an early intervention for this pathology in view of the demonstrable evidence of efficacy. More broadly, the majority of studies included in this systematic review and meta-analysis were found to be at high or unknown risk of bias (Supplemental Table 11) and therefore pooling their results with a view to making definitive treatment recommendations is problematic.
Moreover, the assertion from the authors that “No trials reported outcomes for quality of life and treatment satisfaction.” is incorrect; NERVES reported patient satisfaction outcomes for treatment satisfaction using a previously validated Likert scale and quality of life was assessed using the widely applied EuroQol -5D-3L questionnaire.1,2,5
In summary, research from our group has demonstrated that the use of TFESI in patients with sciatica of 6 weeks-12 months duration was an effective intervention that obviated the requirement for surgical intervention in ~60% of those patients that received it.5 We strongly recommend that this intervention be considered as an initial alternative to surgery in patients with symptomatic posterolateral disc herniations without significant associated neurological deficits. Finally, the use of meta-analyses of poorly performed studies to draw conclusions on optimal treatment modalities when well-designed RCTs addressing the question are available is not an approach we consider to be advisable.
References:
1. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy 16:199-208, 1990
2. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, et al: Outcome measures for low back pain research. A proposal for standardized use. Spine (Phila Pa 1976) 23:2003-2013, 1998
3. Jensen RK, Kongsted A, Kjaer P, Koes B: Diagnosis and treatment of sciatica. Bmj 367:l6273, 2019
4. Liu C, Ferreira GE, Abdel Shaheed C, Chen Q, Harris IA, Bailey CS, et al: Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ 381:e070730, 2023
5. Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, et al: Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluation. Lancet Rheumatol 3:e347-e356, 2021
Competing interests: No competing interests