Objectives The aim of this network meta-analysis is to assess the effectiveness of therapeutic strategies for patients with radiculopathy, including physical, medical, surgical, and other therapies. Methods We electronically searched electronic databases including PubMed and Embase for randomized controlled trials. The response rate and visual analog scale of pain change were considered as primary outcomes. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or standardized mean difference (MD) with 95% CrIs. Besides, surface under cumulative ranking curve (SUCRA) were performed to rank efficacy and safety of treatments on each end points. Results A total of 16 eligible studies with 1071 subjects were included in this analysis. Our results showed that corticosteroid was significantly more effective than control regarding the response rate (OR = 3.86, 95% CrI: 1.16, 12.55). Surgery had a better performance in pain change compared with control (MD = -1.92, 95% CrI: -3.58, -0.15). According to the SUCRA results, corticosteroid, collar, and physiotherapy ranked the highest concerning response rate (SUCRA = 0.656, 0.652, and 0.610, respectively). Surgery, traction, and corticosteroid were superior to others in pain change (SUCRA = 0.866, 0.748, and 0.589, respectively). Conclusion According to the network meta-analysis result, we recommended surgery as the optimal treatment for radiculopathy patients; traction and corticosteroids were also recommended for their beneficial interventions.
BACKGROUND: As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.
QUESTIONS/PURPOSES: In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.
METHODS: We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.
RESULTS: Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.
CONCLUSIONS: The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.
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 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.
PURPOSE: To investigate the effectiveness and safety of epidural steroid injections in patients with lumbar spinal stenosis (LSS).
METHODS: We performed a search on the CENTRAL, Pubmed, Embase and Cochrane databases up to September 2014. We recovered 17 original articles, of which only 10 were in full compliance with the randomized controlled trial (RCT) criteria. These articles were reviewed in an independent and blinded way by two reviewers who were previously trained to extract data and score their quality by the criteria of the Cochrane Handbook (5.1.0).
RESULTS: We accepted ten studies with 1,010 participants. There is minimal evidence that shows that epidural steroid injections are better than lidocaine alone, regardless of the mode of epidural injection. There is a fair short-term and long-term benefit for treating spinal stenosis with local anesthetic and steroids.
CONCLUSIONS: This meta-analysis suggests that epidural steroid injections provide limited improvement in short-term and long-term benefits in LSS patients.
CONTEXT: Lumbar central spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural injections are contemplated in the management of lumbar spinal stenosis.
EVIDENCE ACQUISITION: Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural injections in the management of central lumbar spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural injections used in the management of lumbar central spinal stenosis. Methodological quality assessment and grading of the evidence was performed.
RESULTS: The evidence in managing lumbar spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural injections. For transforaminal epidural injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one.
CONCLUSIONS: The available evidence suggests that epidural injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural injections, whereas it is Level III for short-term improvement only with transforaminal epidural injections.
BACKGROUND CONTEXT: Epidural steroid injections (ESIs) have been used for a number of years in the treatment of radicular pain caused by nerve root impingement or stenosis after failed conservative treatments with oral medications, physical therapy, and lifestyle modifications.
PURPOSE: The purpose of this study was evaluation of predictive tools for ESI outcomes in treating radicular pain.
STUDY DESIGN: This was a comprehensive, systematic review of the prognostic accuracy of certain predictive methods used to determine ESI outcomes.
METHODS: Fifty articles were obtained via the PubMed database, using keywords and cross-referencing works cited. Inclusion criteria included patients with radicular pain, analysis of a specific prediction tool, and outcomes measured by improvement in pain and/or function. Exclusion criteria included literature review articles and animal or cadaver studies. Eight articles studying imaging techniques or laboratory markers as prediction tools underwent quality evaluation and evidence classification based on the 2011 American Academy of Neurology Clinical Practice Guideline Process Manual.
RESULTS: For patients with radicular pain, there is insufficient evidence to either support or refute the prognostic accuracy of spinal stenosis seen on imaging in determining epidural steroid outcomes (two Class IV studies). It is possible that low-grade nerve root compression as seen on lumbar magnetic resonance images does predict short-term reduction in pain after transforaminal ESI (Class II and III studies). For patients with lumbar radicular pain, there is both insufficient and conflicting evidence that either supports or refutes prognostic accuracy of high-sensitivity C-reactive protein in determining epidural steroid outcomes (two Class III studies). It is probable that interferon gamma (IFN-γ) more than 10 pg/mL from epidural lavage is predictive of short-term pain reduction after lumbar ESI (single Class I study). There is insufficient evidence that either supports or refutes prognostic accuracy of fibronectin-aggrecan complex from epidural lavage to determine epidural steroid outcome (single Class IV study).
CONCLUSIONS: Predictive tools for ESI outcomes, such as nerve root compression grading and inflammatory markers, particularly, elevated IFN-γ from epidural lavage fluid, seem promising in the future. At this time, future research is needed with a larger sample size, broader spectrum of patients, and a more defined system of outcome measurements at standardized follow-up periods before practice recommendations can be made.
BACKGROUND CONTEXT: Cervical spine disc herniation is a disabling source of cervical radiculopathy. However, little is known about its course and prognosis. Understanding the course and prognosis of symptomatic cervical disc herniation is necessary to guide patients' expectations and assist clinicians in managing patients.
PURPOSE: To describe the natural history, clinical course, and prognostic factors of symptomatic cervical disc herniations with radiculopathy.
STUDY DESIGN: Systematic review of the literature and best evidence synthesis.
METHODS: A systematic search of MEDLINE, EMBASE, CINAHL, SportsDiscus, and the Cochrane Central Register of Controlled Trials from inception to 2013 was conducted to retrieve eligible articles. Eligible articles were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results from articles with low risk of bias were analyzed using best evidence synthesis principles.
RESULTS: We identified 1,221 articles. Of those, eight articles were eligible and three were accepted as having a low risk of bias. Two studies pertained to course and one study pertained to prognosis. Most patients with symptomatic cervical disc herniations with radiculopathy initially present with intense pain and moderate levels of disability. However, substantial improvements tend to occur within the first 4 to 6 months post-onset. Time to complete recovery ranged from 24 to 36 months in, approximately, 83% of patients. Patients with a workers' compensation claim appeared to have a poorer prognosis.
CONCLUSIONS: Our best evidence synthesis describes the best available evidence on the course and prognosis of cervical disc herniations with radiculopathy. Most patients with symptomatic cervical spine disc herniation with radiculopathy recover. Possible recurrences and time to complete recovery need to be further studied. More studies are also needed to understand the prognostic factors for this condition.
BACKGROUND: The superiority of transforaminal epidural steroid injections (TFESI) vs. interlaminar epidural steroid injections (ILESI) for treating unilateral lumbosacral radicular pain (LSRP) is unproven.
OBJECTIVE: To assess studies comparing TFESI to ILESI for unilateral LSRP for pain relief and functional improvement.
STUDY DESIGN: Systematic review of comparative studies.
METHODS: A systematic literature search was conducted using the Cochrane Central Register of Controlled Trials, PubMed, and Scopus databases for trials reported in English. Studies meeting the Cochrane Review criteria for randomized trials and the AHCQ criteria for observational studies were included. Evidence was graded using the USPSTF classification.
RESULTS: Five (prospective) and 3 (retrospective) studies were included assessing 506 patients. Statistical analysis was calculated only utilizing the 5 prospective studies and consisted of 249 patients with an average of 3.2 months follow-up. In the short-term (2 weeks), there was a 15% difference favoring TFESI vs. ILESI for pain relief. There was no efficacy difference at one or 6 months. Combined pain improvements in all 5 prospective studies revealed < 20% difference between TFESI and ILESI (54.1% vs. 42.7%). There was slightly better functional improvement in ILESI groups (56.4%) vs. TFESI groups (49.4%) at 2 weeks. Combined data showed slight differences (TFESI 40.1% and ILESI 44.8%).
LIMITATIONS: The limitations of this systematic review include the relative paucity of comparative studies.
CONCLUSIONS: The findings show that both TFESI and ILESI are effective in reducing pain and improving functional scores in unilateral LSRP. In the treatment of pain, TFESI demonstrated non-clinically significant superiority to ILESI only at the 2-week follow-up. Based on 2 studies, ILESI demonstrated non-clinically significant superiority to TFESI in functional improvement.
Journal»European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
OBJECTIVE: General practitioners refer patients with continued neck pain that do not respond well to conservative care frequently to secondary care for further assessment. Are surgical interventions to the cervical spine effective when compared to conservative care for patients with neck pain?
DESIGN: Systematic review.
METHOD: The search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to June 2011. Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of adults with neck pain, which evaluated at least one clinically relevant primary outcome measure (e.g. pain, functional status, recovery), were included. In addition, treatments had to include surgery and conservative care. Two authors independently assessed risk of bias using the criteria recommended by the CBRG and extracted the data. The quality of the evidence was rated using the GRADE method.
RESULTS: Patients included had neck pain with or without radiculopathy or myelopathy. In total, three RCTs and six CCTs were identified comparing different surgical interventions with conservative care, of which one had a low risk of bias. Overall there is very low quality of evidence available on the effectiveness of surgery compared to conservative care in neck pain patients showing overall no differences.
CONCLUSION: Most studies on surgical techniques comparing these to conservative care showed a high risk of bias. The benefit of surgery over conservative care is not clearly demonstrated.
Objectives The aim of this network meta-analysis is to assess the effectiveness of therapeutic strategies for patients with radiculopathy, including physical, medical, surgical, and other therapies. Methods We electronically searched electronic databases including PubMed and Embase for randomized controlled trials. The response rate and visual analog scale of pain change were considered as primary outcomes. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or standardized mean difference (MD) with 95% CrIs. Besides, surface under cumulative ranking curve (SUCRA) were performed to rank efficacy and safety of treatments on each end points. Results A total of 16 eligible studies with 1071 subjects were included in this analysis. Our results showed that corticosteroid was significantly more effective than control regarding the response rate (OR = 3.86, 95% CrI: 1.16, 12.55). Surgery had a better performance in pain change compared with control (MD = -1.92, 95% CrI: -3.58, -0.15). According to the SUCRA results, corticosteroid, collar, and physiotherapy ranked the highest concerning response rate (SUCRA = 0.656, 0.652, and 0.610, respectively). Surgery, traction, and corticosteroid were superior to others in pain change (SUCRA = 0.866, 0.748, and 0.589, respectively). Conclusion According to the network meta-analysis result, we recommended surgery as the optimal treatment for radiculopathy patients; traction and corticosteroids were also recommended for their beneficial interventions.
