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Lewis R, Williams N, Matar HE, et al. The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model. Southampton (UK): NIHR Evaluation, Trials and Studies Coordinating Centre (UK); 2011 Nov. (Health Technology Assessment, No. 15.39.)

Cover of The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model

The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model.

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The review findings provide support for the effectiveness of currently used invasive treatments for treating sciatica, such as disc surgery and epidural corticosteroid injections; however, these were also associated with more adverse effects than usual care. They also provide support for the effectiveness of non-opioid medication for reducing pain in sciatica. Chemonucleolysis was also effective for reducing pain, but is no longer used in the UK NHS. With the exception of non-opioids, there were only a few studies evaluating each of the non-invasive treatment categories. The findings of these studies do not provide support for the effectiveness of opioid analgesia, which is widely used in this patient group. The mixed treatment analyses and limited pair-wise analyses suggest that less frequently used treatments such as acupuncture and experimental treatments such as anti-inflammatory biological agents may be effective. There was also a limited evidence base showing that spinal manipulation and exercise therapy may be effective. The findings do not support the use of activity restriction or traction.

The MTC method enabled both the simultaneous comparison of all treatment categories and the comparison of treatments that had not been directly compared in RCTs or observational studies. However, encouraging results for the interventions (e.g. biological agents) from a small number of poor-quality studies need to be treated with caution. Sciatica is generally treated using a stepped-care approach, starting with non-invasive treatments, such as non-opioid medication, and progressing, if necessary, to more invasive treatments, such as epidural injections or surgery. This means that the population of patients treated with non-invasive treatments in the MTC analyses is likely to differ from that treated with invasive treatments, which may have affected the MTC findings. However, the findings of the pair-wise and MTC analyses were broadly similar.

In terms of cost-effectiveness, the argument for stepped approaches based on an initial treatment with non-opioids, relative to direct referral for surgery, was apparent and, although there are a number of limitations associated with the economic model, this finding was shown to be relatively robust.

Further RCTs with concurrent economic evaluation are needed to evaluate the use of biological agents and acupuncture compared with interventions that are currently being used in practice, such as non-opioids and epidural injections. Four RCTs comparing biological agents with placebo that are in progress, have been identified from searches of trial registries (see Appendix 4). Further research is also needed comparing the use of opioids with drugs used to treat neurogenic nerve pain or other treatments currently used in practice. One RCT of oral morphine compared with nortriptyline or placebo was identified from the trial registries (see Appendix 4). Further work is also needed to develop alternative economic modelling approaches to assess the relative cost-effectiveness of treatment regimes in these proposed trials.

© 2011, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK99294
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