Description of non-opioids studies Summary of interventions
Thirty-six studies evaluated the use of non-opioids for sciatica,6,57,80,143,156,161,172,175,214–241 25 of which
compared non-opioids with alternative interventions.6,57,80,143,156,162,173,176,214–230 (Two studies were
reported in a single publication;223 studies 696 and 99999.) Seven studies included more than two
arms.57,166,214,215,223,227,229 The types of intervention being evaluated by the studies are presented in
Table 45a. Three studies161,172,226 did not report any pain, global or CSOM data.161,172,226
Fifteen studies compared different types of non-opioids223,227,229,231–241 (seven of which were
three-arm studies57,215,223,227,229 and two studies of which were reported in a single publication223).
The types of non-opioids being compared are presented in Table 45b but the findings are not considered further.
Summary of study participants for non-opioids
Summary data for included participants are presented in Table 46. The number of participants included in the 22 studies that reported outcome data for global effect, pain or CSOMs ranged from 10 to 532 participants (median 65 participants). Nine studies (41%) included patients with acute sciatica and six studies (27%) included patients with chronic sciatica, whereas the majority of the remaining studies included patients with either acute or chronic sciatica (one study did not report this information). Two studies (one in which the comparator was epidural156 and one
in which the comparator was opioids229) included some patients with spinal stenosis and none
included patients with sequestered or extruded discs. The diagnosis of sciatica, or the presence of herniated disc, was confirmed by imaging in eight studies (38%). One study57 compared the
use of non-opioids with disc surgery in patients who had recurrent sciatica. The remaining studies included a mixture of patients with either first-episode or recurrent sciatica or, more likely, did not report this information. One study (comparator was inactive control)6 included
patients who had not received any previous treatment for their current episode of sciatica. Eleven studies (50%) included patients who had received previous treatment for their current episode of sciatica and this information was not stated in the remaining studies. Two studies that compared non-opioids with disc surgery80 or epidural156 included patients who had received previous
disc surgery.
Summary of study quality for non-opioids studies
Summary information on study details is presented in Table 47. Most of the non-opioid studies were RCTs (17/21, 81%), but none was good quality. Ten studies6,143,161,214,218,220,223,224,227,228
were of moderate quality, most of which compared non-opioids with inactive control. Two of these studies214,227 used adequate methods for random sequence generation and allocation
concealment (comparators included inactive control, opioids and mixed treatment). A further two studies156,224 used adequate randomisation, but not allocation concealment, although both
used sealed envelopes. Two studies218,222 used adequate allocation concealment, but the method of
randomisation was unclear. Only one study214 had strong external validity, although it had a high
attrition rate.
Non-opioids results at short-term follow-up (≤ 6 weeks) Global effect at short-term follow-up
The results for the global effect at short-term follow-up are presented in Table 48 and the accompanying forest plot (Figure 34). Non-opioids were compared with inactive control and opioids. One study221 included only patients with chronic sciatica, five studies218,220,223,224,227
TABLE 45a Summary of the interventions used when comparing non-opioids with alternative interventions (grouped by comparator then ordered by author)
ID no. Author, year Study design Treatment description Control description
Non-opioids vs alternative/non-traditional
801 Chen, 2009215
RCT Western medicine – oral nimesolide (NSAIDs) 2 g
daily for 10 days (WMG) Warming acupuncture by burning moxa daily for 10 days (WAG) 801 Chen,
2009215
RCT Western medicine – oral nimesolide (NSAIDs) 2 g
daily for 10 days (WMG) Anisodamine (2 mg) point injections into acupoints daily for 10 days (PIG)
Non-opioids vs biological agents
323 Genevay,
2004216 HCS Three intravenous injections of methylprednisolone 250 mg Three subcutaneous injections of etanercept (Enbrel®, Wyeth Pharmaceuticals) 25 mg (anti- TNF-α)
Non-opioids vs disc surgery
475 Dubourg, 200280
CCS Non-operative intervention group. Some received
steroids Disc surgery (operative group) (various surgical techniques) 144 Rossi,
199357 (Italian language)
RCT Oral dexamethasone 8 mg for 9 days, naproxen
500–1000 mg for 5 days (group Ib) Percutaneous discectomy (groups Ia and IIa)
144 Rossi, 199357 (Italian language)
RCT Oral dexamethasone 8 mg for 9 days, naproxen
500–1000 mg for 5 days (group Ib) Microdiscectomy (group IIb)
Non-opioids vs epidural/intradiscal injection
451 Bronfort, 2000161
RCT Paracetamol, NSAIDs, activity modification Epidural injection of steroid injections, 1–3 injections
20 Dincer, 2007143
RCT Oral diclofenac 75 mg for 14 days (NSAID) Caudal epidural injection 40 mg methylprednisolone acetate, 8 mg dexamethasone phosphate, 7 ml of 2% prilocaine
771 Lafuma, 1997172
RCT Usual care (rest + NSAIDs) without epidural
injections during hospital admission Epidural steroid (125 mg prednisolone) injections at admission 362 Wilson-
MacDonald, 2005156
RCT Intramuscular injections of steroid
methylprednisolone 80 mg and local anaesthetic 8 ml bupivacaine
Epidural injection of steroid methylprednisolone 80 mg and local anaesthetic 8 ml bupivacaine 846 Murata,
2009175 RCT Injection of steroid (3.3 mg dexamethasone sodium phosphate) and local anaesthetic (7 ml 1% lidocaine) in the back muscles of L2 area (control block)
L2 nerve block using steroid (3.3 mg dexamethasone sodium phosphate) and local anaesthetic (2 ml of 1% lidocaine)
Non-opioids vs inactive control
696 Dreiser, 2001223
RCT Oral meloxicam (NSAID) 7.5 mg for 7 days (M I) Oral placebo for 7 days 696 Dreiser,
2001223
RCT Oral meloxicam (NSAID) 15 mg for 7 days (M II) Oral placebo for 7 days 334 El-Zahaar,
1995221 RCT Intravenous injections of colchicine 1 mg twice weekly for 3 weeks Intravenous injections of saline twice weekly for 3 weeks 728 Finckh,
2006224
RCT Intravenous steroid methylprednisolone 500 mg Intravenous saline infusion (placebo) 62 Gibson,
1975217 Non-RCT Chymoral tablets (proteolytic enzymes) for 7 days Placebo tablets for 7 days
ID no. Author, year Study design Treatment description Control description 97 Goldie,
1968218 RCT Oral indomethacin 75 mg daily Oral placebo 732 Grevsten,
1975225
RCT Phenylbutazone (NSAID) 300–600 mg for 15 days Intramuscular and oral placebo 312 Hedeboe,
1982220 RCT Intramuscular injection dexamethasone (8–64 mg) for 7 days Intramuscular injection of saline 816 Herrmann, 2009227 RCT Lornoxicam 8 mg Placebo 816 Herrmann, 2009227 RCT Diclofenac 50 mg Placebo 817 Holve,
2008228 Q-RCT Steroid oral tablets (prednisolone decreasing dose from 60 mg to 20 mg every 3 days) + standard medical + PT
Placebo tablets + standard medical + PT
736 Jacobs, 1968226
Q-RCT Oral indomethacin (NSAID) 75–100 mg for 7 days Oral placebo for 7 days 534 Khoromi
2007214 RCT (crossover) Oral nortriptyline (Allegron
®, King Pharmaceuticals)
plus inert placebo (up to 100 mg/day for 7.5 weeks) Oral benztropine (active placebo) plus inert placebo (0.25–1 mg/day for 8.5 weeks) 611 Porsman,
1979222
RCT Intramuscular dexamethasone 8–64 mg for 7 days Intramuscular saline for 7 days (placebo) 665 Weber,
19936
RCT Oral pirixicam (NSAID) 20–40 mg for 14 days Oral placebo for 14 days 297 Yildirim,
2003219 RCT Oral gabapentin 900–3600 mg for 2 months Oral placebo for 2 months Non-opioids vs manipulation
451 Bronfort, 2000161
RCT Paracetamol, NSAIDs, activity modification Chiropractic spinal manipulation
Non-opioids vs mixed treatment
534 Khoromi 2007214
RCT
(crossover) Oral nortriptyline plus inert placebo (up to 100 mg/day for 7.5 weeks) (Opioids + non-opioids). Morphine plus nortriptyline (oral morphine up to 90 mg/day for 8.5 weeks; oral nortriptyline up to 100 mg/day for 7.5 weeks)
Non-opioids vs opioids
534 Khoromi
2007214 RCT (crossover) Oral nortriptyline plus inert placebo (up to 100 mg/day for 7 weeks) Sustained-release morphine (oral) plus inert placebo (up to 90 mg/day for 7 weeks) 368 Kwasucki,
2002229 (Polish language)
RCT Fluvoxamine (10 mg oral) Tramadol (100 mg intramuscular injection)
368 Kwasucki, 2002229 (Polish language)
RCT Imipramine (25 mg oral) Tramadol (100 mg intramuscular injection)
547 Kwasucki, 1993230 (Polish language)
RCT Dexamethasone. First and second days 24 mg (16 mg at 7 am, 8 mg at 7 pm); third day 8 mg twice
daily; fourth and fifth days 4 mg twice daily; sixth and seventh days 4 mg once daily
Tramadol. First 5 days 100 mg twice daily; sixth and seventh days 100 mg once daily
M, meloxican; PIG, point injection group; TNF-α, tumour necrosis factor-alpha; WAG, warming acupuncture group; WMG, western medicine group. TABLE 45a Summary of the interventions used when comparing non-opioids with alternative interventions (grouped by comparator then ordered by author) (continued)