Effectiveness of non-surgical interventions for patients with chronic sciatica: a systematic review with network meta-analysis

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 (4,920 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 leg pain 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.