The objective of the study was to investigate the comparative effectiveness of non-surgical interventions for adults with chronic sciatica. EMBASE, MEDLINE, Cochrane Library, and CINAHL were searched until 7th June 2024 for randomized controlled trials (RCTs) of non-surgical interventions in adults (aged 18 or older) with chronic sciatica (3 months or longer). Primary outcomes were leg pain intensity and physical function at short-, medium-, and long-term follow-up. Two reviewers independently conducted the screening process, data extraction, and risk of bias assessment (with the Cochrane risk of bias 2.0 tool). Frequentist random effects network meta-analysis was conducted, and evidence confidence was evaluated with the CINEMA method. Fifty RCTs (4920 participants) were included. At short-term, spinal manipulative therapy (mean difference [MD] - 61.01, 95 % CI - 94.64 to - 27.39), exercise + neural mobilization (MD - 60.01, - 93.08 to - 26.95), and soft tissue anesthetic injections (MD - 60.01, - 99.08 to - 20.95) showed the largest reductions in leg pain intensity versus placebo (all based on very low confidence evidence). Epidural magnesium injections improved physical function at short-term (MD - 40.45, - 54.00 to - 26.89; very low confidence). Long-term reductions in physical function occurred with epidural steroid + ketamine injections (MD -15.51, - 21.50 to - 9.52) and epidural injections + physical therapy (MD - 12.01, - 17.27 to - 6.75; very low confidence). In summary, the evidence is very uncertain regarding the effectiveness of non-surgical interventions in patients with chronic sciatica. Future RCTs should minimize bias and include larger sample sizes to improve the confidence on the evidence base for chronic sciatica. PROTOCOL REGISTRATION: PROSPERO (CRD42022361572). PERSPECTIVE: Currently, no high-quality evidence confirms the superior effectiveness of any non-surgical intervention for patients with chronic sciatica. While some treatments may provide short-term leg pain relief, the very low confidence of the evidence highlights the need for rigorous and large-scale trials to better guide clinical decision-making.
| Discipline Area | Score |
|---|---|
| Rehab Clinician (OT/PT) |  |
| Physician |  |
Physician rater
Exercise with education, spinal manipulative therapy, and epidural injections may provide short-term symptomatic relief for patients with chronic sciatica, but there is often a lack of strong evidence for medium- or long-term benefits, as well as detailed co-intervention information. Further high-quality research is needed. The authors acknowledge the limitations of their study.
Physician rater
In patients with chronic sciatica, short-term relief of leg pain has been observed following spinal manipulation, exercise combined with neural mobilisation, and epidural injections (including steroid, ketamine, magnesium, and oxygen-ozone). However, these findings are not robust enough to inform firm clinical recommendations. Physicians should also be aware of the weak evidence supporting the long-term benefits of co-interventions, and consider this alongside patient-specific factors and preferences.
Rehab Clinician (OT/PT) rater
The authors admit to a number of limitations of the study. The results show low confidence for effectiveness. They also caution not to use the information in clinical practice, so it does not provide much useful information for the clinician. I normally like meta-analyses because of the richness of information in one spot. Not all research provides us with positive information to apply in our clinical practice. This paper has value for us by pointing out how poor many treatments are for chronic non-surgical sciatica. It is little wonder these cases present a challenge in clinical practice.
Rehab Clinician (OT/PT) rater
The presence of chronic sciatica points toward an heterogenous pathology, one that demands careful clinical analysis and MRI imaging of individual presentations. As indicated by this study, generalisation demonstrates an inappropriate fit for identifying an evidence-based therapeutic intervention.
, McMaster University