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Hammed A, Al-Qiami A, Alsalhi H, Almansi A, Massoud M, Alzawahreh A, Hamouda A, Tanislav C. Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis. Cureus 2024; 16:e59617. [PMID: 38832179 PMCID: PMC11145364 DOI: 10.7759/cureus.59617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
Sciatica, characterized by leg or back symptoms along the sciatic nerve pathway, often manifests as a chronic condition lasting over 12 weeks. Decision-making between nonoperative treatment and immediate microdiscectomy for chronic sciatica remains challenging, due to the complex relationship between symptom duration, severity, and lumbar discectomy outcomes. In this systematic review, we conducted a comprehensive search across Scopus, PubMed, Web of Science, and the Cochrane Library, identifying relevant two-arm clinical trials up to September 2023. Rigorous screening and data extraction were performed by two independent reviewers, with study quality evaluated using the risk of bias 2 (RoB) tool. This meta-analysis incorporated four studies comprising 352 participants. Our analysis revealed that conservative treatment was associated with a significant reduction in leg pain and improvement in, SF mental, and physical scores compared to surgical intervention. However surgical treatment demonstrated significant improvement in back pain. In conclusion, our findings suggest that surgical intervention may be more effective than non-surgical treatment for chronic sciatica-related back pain. Conservative treatment significantly reduces leg pain while improving mental and physical health outcomes. Ultimately, our findings support conservative as the initial approach unless surgery is warranted, particularly in cases with neurological deficits or cauda equina syndrome.
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Affiliation(s)
- Ali Hammed
- Department of Geriatrics and Neurology, Diakonie Hospital Jung Stilling, Siegen, DEU
| | - Almonzer Al-Qiami
- Neurological Surgery, Faculty of Medicine, Kassala University, Kassala, SDN
| | - Hamza Alsalhi
- Negida Academy, Medical Research Group of Egypt, Arlington, USA
- Faculty of Medicine, Hashemite University, Amman, JOR
| | | | - Mahmoud Massoud
- Neurology, Faculty of Medicine, Al-Azhar University, Damietta, EGY
| | - Ahmad Alzawahreh
- Neurology, Faculty of Medicine, The Hashemite University, Zarqaa, JOR
| | | | - Christian Tanislav
- Department of Geriatrics and Neurology, Diakonie Hospital Jung Stilling, Siegen, DEU
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Song Y, Li T, Ma C, Liu H, Liang F, Yang Y. Comparative efficacy of acupuncture-related therapy for migraine: A systematic review and network meta-analysis. Front Neurol 2022; 13:1010410. [DOI: 10.3389/fneur.2022.1010410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMigraine is a worldwide disabling chronic brain disorder, some studies suggest acupuncture-related therapy plays an important role in raising efficiency rates and reducing migraine attacks. However, clinical trials comparing the efficacy of different interventions for migraine are limited and controversial. This network meta-analysis (NMA) was performed to review all randomized controlled trials (RCTs) comparing the effects of acupuncture-related therapy for migraine.MethodsRandomized controlled trials (RCTs) of acupuncture-related therapy for migraine were searched in the following databases from the date of database inception to March 31, 2022, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), VIP Database, Wanfang Database, and Chinese Biomedical Database (CBM). The primary endpoint was visual analog scale (VAS) scores. The secondary endpoints were the number of migraine days, duration of migraine, and frequency of migraine attacks. We used Cochrane risk of bias to assess the quality of evidence for outcomes.ResultsThirty-nine studies involving 4379 patients with 13 different acupuncture-related methods were evaluated. According to surface under the cumulative ranking curve value, acupoint injection was ranked the highest (98.0%) in VAS scores, followed by acupoint implantation (79.0%); electroacupuncture was the optimal intervention method (82.4%) in the number of migraine days, followed by embedding needle therapy (73.1%); embedding needle therapy ranked first (99.9%) in the duration of migraine, followed by acupoint injection (77.4%); acupoint injection was the best intervention (99.3%) in the frequency of migraine attacks, followed by conventional acupuncture plus massage (73.8%).ConclusionThese results provide preliminary evidence that acupuncture-related therapy could be recommended as one of the effective treatments for migraine. Conventional acupuncture has significant effects on improving VAS scores, the number of migraine days, duration of migraine, and frequency of migraine attacks. However, more high-quality studies should be carried out to verify this finding.Systematic review registrationhttps://inplasy.com/, identifier: INPLASY202110035.
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Belavy DL, Diwan AD, Ford J, Miller CT, Hahne AJ, Mundell N, Tagliaferri S, Bowe S, Pedder H, Saueressig T, Zhao X, Chen X, Balasundaram AP, Arora NK, Owen PJ. Network meta-analysis for comparative effectiveness of treatments for chronic low back pain disorders: systematic review protocol. BMJ Open 2021; 11:e057112. [PMID: 34845083 PMCID: PMC8634013 DOI: 10.1136/bmjopen-2021-057112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Chronic low back pain disorders (CLBDs) present a substantial societal burden; however, optimal treatment remains debated. To date, pairwise and network meta-analyses have evaluated individual treatment modes, yet a comparison of a wide range of common treatments is required to evaluate their relative effectiveness. Using network meta-analysis, we aim to evaluate the effectiveness of treatments (acupuncture, education or advice, electrophysical agents, exercise, manual therapies/manipulation, massage, the McKenzie method, pharmacotherapy, psychological therapies, surgery, epidural injections, percutaneous treatments, traction, physical therapy, multidisciplinary pain management, placebo, 'usual care' and/or no treatment) on pain intensity, disability and/or mental health in patients with CLBDs. METHODS AND ANALYSIS Six electronic databases and reference lists of 285 prior systematic reviews were searched. Eligible studies will be randomised controlled/clinical trials (including cross-over and cluster designs) that examine individual treatments or treatment combinations in adult patients with CLBDs. Studies must be published in English, German or Chinese as a full-journal publication in a peer-reviewed journal. A narrative approach will be used to synthesise and report qualitative and quantitative data, and, where feasible, network meta-analyses will be performed. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance, including the network meta-analysis extension (PRISMA-NMA). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for network meta-analysis will be implemented for assessing the quality of the findings. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review of the published data. Findings will be disseminated via peer-reviewed publication. PROSPERO REGISTRATION NUMBER PROSPERO registration number CRD42020182039.
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Affiliation(s)
- Daniel L Belavy
- Physiotherapy, Hochschule fur Gesundheit, Bochum, Nordrhein-Westfalen, Germany
| | - Ashish D Diwan
- Department of Orthopaedic Surgery, Spine Service, St. George Hospital, Kogarah, New South Wales, Australia
| | - Jon Ford
- Advance Healthcare, Melbourne, Victoria, Australia
- Low Back Research Team, La Trobe University, Bundoora, Victoria, Australia
| | - Clint T Miller
- Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, Victoria, Australia
| | - Andrew J Hahne
- Low Back Research Team, La Trobe University, Bundoora, Victoria, Australia
| | | | | | - Steven Bowe
- Biostatistics Unit, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Hugo Pedder
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Xiaohui Zhao
- Xi'an University of Architecture and Technology, Xi'an, China
| | - Xiaolong Chen
- Department of Orthopaedic Surgery, Spine Service, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Nitin Kumar Arora
- Physiotherapy, Hochschule fur Gesundheit, Bochum, Nordrhein-Westfalen, Germany
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India
| | - Patrick J Owen
- Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, Victoria, Australia
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Wang X, Martin G, Sadeghirad B, Darzi AJ, Couban RJ, Florez ID, Crandon HN, Kum E, Chang Y, Esfahani MA, Sivananthan L, Mehrabi F, Sengupta NK, Rathod P, Morsi RZ, Buckley DN, Guyatt GH, Rampersaud YR, Standaert CJ, Agoritsas T, Busse JW. Interventional treatments for chronic, axial or radicular, non-cancer, spinal pain: a protocol for a systematic review and network meta-analysis of randomised trials. BMJ Open 2021; 11:e046025. [PMID: 34244262 PMCID: PMC8273478 DOI: 10.1136/bmjopen-2020-046025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Chronic, non-cancer, axial or radicular spinal pain is a common condition associated with considerable socioeconomic burden. Clinicians frequently offer patients various interventional procedures for the treatment of chronic spine pain; however, the comparative effectiveness and safety of available procedures remains uncertain. METHODS We will conduct a systematic review of randomised controlled trials that explores the effectiveness and harms of interventional procedures for the management of axial or radicular, chronic, non-cancer, spine pain. We will identify eligible studies through a systematic search of Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science from inception without language restrictions. Eligible trials will: (1) enrol primarily adult patients (≥18 years old) with axial or radicular, chronic, non-cancer, spine pain, (2) randomise patients to different, currently available, interventional procedures or to an interventional procedure and a placebo/sham procedure or usual care, and (3) measure outcomes at least 1 month after randomisation.Pairs of reviewers will independently screen articles identified through searches and extract information and assess risk of bias of eligible trials. We will use a modified Cochrane instrument to evaluate risk of bias. We will use frequentist random-effects network meta-analyses to assess the relative effects of interventional procedures, and five a priori hypotheses to explore between studies subgroup effects. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome, including direct, indirect and network estimates. ETHICS AND DISSEMINATION No research ethics approval is required for this systematic review, as no confidential patient data will be used. We will disseminate our findings through publication in a peer-reviewed journal and conference presentations, and our review will support development of a BMJ Rapid Recommendations providing contextualised clinical guidance based on this body of evidence. PROSPERO REGISTRATION NUMBER CRD42020170667.
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Affiliation(s)
- Xiaoqin Wang
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Grace Martin
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
| | - Rachel J Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Ivan D Florez
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Holly N Crandon
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Meisam Abdar Esfahani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Fatemeh Mehrabi
- Pharmaceutic Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Neil K Sengupta
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Preksha Rathod
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - D Norman Buckley
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Y Raja Rampersaud
- Arthritis Program, Krembil Research Institute, Division of Orthopaedics, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher J Standaert
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Thomas Agoritsas
- Division General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Jason W Busse
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
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Does Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis. Curr Pain Headache Rep 2020; 24:26. [DOI: 10.1007/s11916-020-00859-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Patel R, Urits I, Orhurhu V, Orhurhu MS, Peck J, Ohuabunwa E, Sikorski A, Mehrabani A, Manchikanti L, Kaye AD, Kaye RJ, Helmstetter JA, Viswanath O. A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache. Curr Pain Headache Rep 2020; 24:24. [DOI: 10.1007/s11916-020-00860-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Merkow J, Varhabhatla N, Manchikanti L, Kaye AD, Urman RD, Yong RJ. Minimally Invasive Lumbar Decompression and Interspinous Process Device for the Management of Symptomatic Lumbar Spinal Stenosis: a Literature Review. Curr Pain Headache Rep 2020; 24:13. [PMID: 32072362 DOI: 10.1007/s11916-020-0845-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Symptomatic lumbar spinal stenosis (LSS) is a condition affecting a growing number of individuals resulting in significant disability and pain. Traditionally, treatment options have consisted of conservative measures such as physical therapy, medication management, epidural injections and percutaneous adhesiolysis, or surgery. There exists a treatment gap for patients failing conservative measures who are not candidates for surgery. Minimally invasive lumbar decompression (MILD®) and interspinous process device (IPD) with Superion® represent minimally invasive novel treatment options that may help fill this gap in management. We performed a literature review to separately evaluate these procedures and assess the effectiveness and safety. RECENT FINDINGS The available evidence for MILD and Superion has been continuously debated. Overall, it is considered that while the procedures are safe, there is only modest evidence for effectiveness. For both procedures, we have reviewed 13 studies. Based on the available evidence, MILD and Superion are safe and modestly effective minimally invasive procedures for patients with symptomatic LSS. It is our recommendation that these procedures may be incorporated as part of the continuum of treatment options for patients meeting clinical criteria.
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Affiliation(s)
- Justin Merkow
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Narayana Varhabhatla
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Alan D Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA.
| | - R Jason Yong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Zhao L, Manchikanti L, Kaye AD, Abd-Elsayed A. Treatment of Discogenic Low Back Pain: Current Treatment Strategies and Future Options—a Literature Review. Curr Pain Headache Rep 2019; 23:86. [DOI: 10.1007/s11916-019-0821-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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9
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Verheijen E, Munts AG, van Haagen O, de Vries D, Dekkers O, van den Hout W, Vleggeert-Lankamp C. Transforaminal epidural injection versus continued conservative care in acute sciatica (TEIAS trial): study protocol for a randomized controlled trial. BMC Neurol 2019; 19:216. [PMID: 31481010 PMCID: PMC6719366 DOI: 10.1186/s12883-019-1445-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/25/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sciatica is a condition that is characterised by radicular pain in the leg and primarily caused by a herniated lumbar intervertebral disk. In addition to leg pain, patients can experience back pain, leg numbness and leg weakness resulting in decreased productivity and social activity. The majority of sciatica cases recovers spontaneously and therefore patients are initially treated conservatively with oral pain medication. However, some patients experience intractable pain that severely impedes them and no consensus exists on the optimal conservative treatment to reduce this discomfort in the acute phase of sciatica. The aim of the TEIAS trial is to assess the effectiveness, cost-effectiveness and predictive capability on patient outcome of transforaminal epidural injection (TEI) compared to treatment with standard pain medication. METHODS This study is designed as a prospective, open-label, mono-centered, randomized controlled trial. Patients that visit their general practitioner with complaints of radicular leg pain and meet the selection criteria are asked to participate in this study. Eligible patients will be randomized to treatment with TEI or to treatment with standard oral pain medication. Treatment of TEI will comprise lidocaine with methylprednisolone acetate for L3 and below and lidocaine with dexamethasone above L3. A total of 142 patients will be recruited and follow-up will occur after 1, 2, 4, 10 and 21 weeks for assessment of pain, functionality, patient received recovery and cost-effectiveness. The primary outcome will be the average score for leg pain at 2 weeks. For this outcome we defined a clinically relevant difference as 1.5 on the 11-point NRS scale. DISCUSSION Adequate conservative treatment in the acute phase of sciatica is lacking, particularly for patients with severe symptoms. Focusing on effectiveness, cost-effectiveness and predictive capability on patient outcome of TEI will produce useful information allowing for more lucid decision making in the conservative treatment of sciatica in the acute phase. TRIAL REGISTRATION This trial is registered in the ClinicalTrials.gov database under registry number NCT03924791 on April 23, 2019.
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Affiliation(s)
- Eduard Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600. 2300, RC Leiden, The Netherlands
| | - Alexander G. Munts
- Department of Neurology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Oscar van Haagen
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Dirk de Vries
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Olaf Dekkers
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert van den Hout
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
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Chen L, H Ferreira P, R Beckenkamp P, L Ferreira M. Comparative efficacy and safety of surgical and invasive treatments for adults with degenerative lumbar spinal stenosis: protocol for a network meta-analysis and systematic review. BMJ Open 2019; 9:e024752. [PMID: 30948574 PMCID: PMC6500367 DOI: 10.1136/bmjopen-2018-024752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Surgical and invasive procedures are widely used in adults with degenerative lumbar spinal stenosis when conservative treatments fail. However, little is known about the comparative efficacy and safety of these interventions. To address this, we will perform a network meta-analysis (NMA) and systematic review to compare the efficacy and safety of surgical and invasive procedures for adults with degenerative lumbar spinal stenosis. METHODS AND ANALYSIS We will include randomised controlled trials assessing surgical and invasive treatments for adults with degenerative lumbar spinal stenosis. We will search AMED, CINAHL, EMBASE, the Cochrane Library and MEDLINE. Only English studies will be included and no restriction will be set for publication status. For efficacy, our primary outcome will be physical function. Secondary outcomes will include pain intensity, health-related quality of life, global impression of recovery, work absenteeism and mobility. For safety, our primary outcome will be all-cause mortality. Secondary outcomes will include adverse events (number of events or number of people with an event) and treatment withdrawal due to adverse effect. Two reviewers will independently select studies, extract data and assess the risk of bias (Revised Cochrane risk-of-bias tool for randomized trials) of included studies. The quality of the evidence will be evaluated through the Grading of Recommendations Assessment, Development and Evaluation framework. Random-effects NMA will be performed to combine all the evidence under the frequentist framework and the ranking results will be presented through the surface under the cumulative ranking curve and mean rank. All analyses will be performed in Stata and R. ETHICS AND DISSEMINATION No ethical approval is required. The research will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018094180.
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Affiliation(s)
- Lingxiao Chen
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paulo H Ferreira
- University of Sydney, Faculty of Health Sciences, Discipline of Physiotherapy, Sydney, New South Wales, Australia
| | - Paula R Beckenkamp
- University of Sydney, Faculty of Health Sciences, Discipline of Physiotherapy, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis. Semin Arthritis Rheum 2019; 49:303-313. [PMID: 30940466 DOI: 10.1016/j.semarthrit.2019.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP). METHODS PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values. RESULTS 58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias. CONCLUSION No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.
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Williams NH, Jenkins A, Goulden N, Hoare Z, Hughes DA, Wood E, Foster NE, Walsh D, Carnes D, Sparkes V, Hay EM, Isaacs J, Konstantinou K, Morrissey D, Karppinen J, Genevay S, Wilkinson C. Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC). Trials 2018; 19:408. [PMID: 30064491 PMCID: PMC6069989 DOI: 10.1186/s13063-018-2801-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early. METHODS A pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months' duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase. RESULTS The internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants. CONCLUSIONS Improved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica. TRIAL REGISTRATION Current Controlled Trials, ISRCTN14569274 . Registered on 15 December 2014.
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Affiliation(s)
- Nefyn H. Williams
- Department of Health Services Research, University of Liverpool, Waterhouse Block B, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Alison Jenkins
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Nia Goulden
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Zoe Hoare
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - Eifiona Wood
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Nadine E. Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - David Walsh
- Arthritis Research UK Pain Centre and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, London, UK
| | - Valerie Sparkes
- School of Healthcare Science, Cardiff University, Cardiff, UK
| | - Elaine M. Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - John Isaacs
- National Institute for Health Research Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Dylan Morrissey
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jaro Karppinen
- Medical Research Centre Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | | | - Clare Wilkinson
- School of Healthcare Sciences, Bangor University, Bangor, UK
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13
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Bagg MK, Salanti G, McAuley JH. Comparing interventions with network meta-analysis. J Physiother 2018; 64:128-132. [PMID: 29661376 DOI: 10.1016/j.jphys.2018.02.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Matthew K Bagg
- Neuroscience Research Australia; Prince of Wales Clinical School & New College Village, University of New South Wales, Sydney, Australia
| | - Georgia Salanti
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - James H McAuley
- Neuroscience Research Australia; School of Medical Sciences, University of New South Wales, Sydney, Australia
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14
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Bagg MK, McAuley JH. Comment: A Comparison of the Efficacy and Tolerability of the Treatments for Sciatica: A Network Meta-Analysis. Ann Pharmacother 2017; 52:97-98. [PMID: 28948841 DOI: 10.1177/1060028017733480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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