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OPTION NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
One systematic review found no significant difference in overall
improvement between non-steroidal anti-inflammatory drugs and placebo
in people with sciatica caused by disc herniation.
Benefits: Versus placebo: We found one systematic review (search date
1998, 3 RCTs, 321 people) of medical treatments for sciatica
caused by disc herniation.13 The RCTs compared non-steroidal
anti-inflammatory drugs (NSAIDs) (piroxicam 40 mg/day for 2 days
or 20 mg/day for 12 days; indometacin [indomethacin] 75�100 mg
3 times daily; phenylbutazone 1200 mg/day for 3 days or 600 mg/
day for 2 days) versus placebo. The review found no significant
difference between NSAIDs and placebo in global improvement
after 5�30 days (pooled AR for improvement in pain: 80/172
[46.5%] with NSAIDs v 57/149 [38.3%] with placebo; OR for global
improvement 0.99, 95% CI 0.60 to 1.70; see comment below).
Harms: The systematic review did not report the adverse effects of NSAIDs.
NSAIDs may cause gastrointestinal complications (see nonsteroidal
anti-inflammatory drugs topic, p 001).
Comment: The absolute numbers in the RCTs relate to the outcomes of
improvement in pain (3 RCTs) and return to work (1 RCT).13
However, the meta-analysis used the outcome measure of global
improvement. The relationship between these measures is unclear.
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OPTION ANALGESICS
We found no systematic review or RCTs on the use of analgesics for
treatment of people with symptomatic herniated lumbar discs.
Benefits: We found no systematic review or RCTs.
Harms: We found no RCTs.
Comment: None.
OPTION ANTIDEPRESSANTS
We found no systematic review or RCTs on the use of antidepressants for
treatment of people with symptomatic herniated lumbar discs.
main/1118_new 24/02/05
Benefits: We found no systematic review or RCTs.
Harms: We found no RCTs.
Comment: None.
OPTION MUSCLE RELAXANTS
We found no systematic review or RCTs on the use of muscle relaxants
for treatment of people with symptomatic herniated lumbar discs.
Benefits: We found no systematic review or RCTs.
Harms: We found no RCTs.
Comment: None.
OPTION EPIDURAL CORTICOSTEROID INJECTIONS
One systematic review found limited evidence that epidural corticosteroid
injections increased global improvement compared with placebo.
However, one subsequent RCT found no significant difference between
epidural corticosteroid injections plus conservative treatment and
conservative treatment alone in pain, mobility, or people returning to
work at 6 months. Another subsequent RCT found no significant
difference between epidural corticosteroid injection and control injection
in pain, disability, or self rated improvement after 35 days.
Benefits: We found one systematic review (search date 1998, 4 RCTs of
epidural corticosteroid, 265 people)13 of medical treatments for
sciatica caused by disc herniation and two subsequent RCTs.14,15
The review compared four different doses of epidural corticosteroid
injections (8 mL methylprednisolone 80 mg; 2mL methylprednisolone
80 mg; 10 mL methylprednisolone 80 mg; and 2mL
methylprednisolone acetate 80 mg) versus placebo (saline or lidocaine
[lignocaine] 2 mL) after follow up periods of 2, 21, and 30
days.13 The review found limited evidence that epidural corticosteroid
increased the proportion of people with self perceived global
improvement (which was not defined) compared with placebo. The
result was of borderline significance (73/160 [45.6%] with steroid v
56/172 [32.5%] with placebo; OR 2.2, 95% CI 1.0 to 4.7). The first
subsequent RCT (36 people with disc herniation confirmed by
magnetic resonance imaging) compared epidural corticosteroid (3
injections of methylprednisolone 100 mg in 10 mL bupivacaine
0.25% during the first 14 days in hospital) plus conservative
non-operative treatment versus conservative treatment alone.14
Conservative treatment involved initial bed rest and analgesia
followed by graded rehabilitation (hydrotherapy, electroanalgesia,
postural exercise classes) followed by physiotherapy. It found no
significant difference between groups in mean pain scores at
6 weeks and 6 months measured on a visual analogue scale (at 6
months: 32.9 [range 0�85.0] with corticosteroids v 39.2 [range
0�100.0] with conservative treatment). It found no significant
difference in mean mobility scores (Hannover Functional Ability
Questionnaire: 61.8 [range 25.0�88.0] with corticosteroids v 57.2
[range 13.0�100.0] with conservative treatment), in the proportion
of people who had back surgery (2/17 [12%] with corticosteroids v
4/19 [21%] with conservative treatment; RR 0.56, 95% CI 0.09 to
2.17), or in people returning to work within 6 months (15/17 [88%]
with corticosteroids v 14/19 [74%] with conservative treatment;
RR 1.19, 95% CI 0.75 to 1.33).14 The second subsequent double
blind RCT (85 people with sciatica caused by herniated disc)
compared epidural corticosteroid injections (2 mL prednisolone
acetate at 2 day intervals for a total of 3 injections) versus control
(2 mL isotonic saline).15 It found no significant difference between
groups in self rated success of treatment after 35 days (people
rating improvement as �recovery� or �marked improvement�: 21/43
[49%] with corticosteroid v 20/42 [48%] with control; P=0.91).
The RCT also found no significant difference between corticosteroid
injection and control injection in pain scores after 35 days (mean
change from baseline measured by unspecified visual analogue
scale: �30.3mm with corticosteroid v �25.2mm with control;
treatment effect �5.1, 95% CI �18.7 to +8.4) or disability/function
(Roland-Morris Index score, mean change from baseline: �5.3 with
corticosteroid v �3.2 with control; treatment effect �2.1, 95% CI
�5.0 to +0. Cool

.15
Harms: No serious adverse effects were reported in the RCTs included in the
systematic review, although 26 people complained of transient
headache or transient increase in sciatic pain.13 The first subsequent
RCT did not report adverse effects of epidural injections.14
The second subsequent RCT reported that clinically significant
adverse effects occurred in 2/43 (5 Confused

people in the corticosteroid
group and 3/42 (7 Confused

people in the control group (P=0.676).15 It
reported that headache occurred in two people in each group, and
thoracic pain occurred in one person with control.
Comment: None.
QUESTION What are the effects of non-drug treatments?
OPTION BED REST
One systematic review of conservative treatment found no RCTs on bed
rest in people with symptomatic herniated discs. One subsequent RCT in
people with sciatica found no significant difference between bed rest and
watchful waiting for 2 weeks in people�s perceived improvement, mean
pain scores, mean disability scores, or mean satisfaction scores after 12
weeks.
Benefits: We found one systematic review13 and one subsequent RCT.16 The
systematic review (search date 1998) of conservative treatments
for sciatica caused by disc herniation identified no RCTs of bed rest
for treatment of people with symptomatic herniated discs.13 The
subsequent RCT (183 people with sciatica, intensity sufficient to
justify 2 weeks of bed rest as treatment) compared bed rest at
home (instructed to stay in the supine or lateral recumbent position
with 1 pillow under the head) versus a control of watchful waiting
(advised to be up and about whenever possible) for 2 weeks.16 Most
people had nerve root compression on magnetic resonance imaging
(109 people out of 161 people who had magnetic resonance
imaging performed). It found no significant difference between bed
rest and control in people�s perceived improvement (87% with bed
rest v 87% with control; OR 1.0, 95% CI 0.4 to 2.9; based on
regression analysis; see comment below), mean pain scores (McGill
Pain Questionnaire: 8 with bed rest v 7 with control; difference �0.6,
95% CI �3.3 to +2.1; based on regression analysis), mean disability
scores (revised Roland Disability Scale: 15.2 with bed rest v 15.7
with control; difference �0.5, 95% CI �2.6 to +1.6; based on
regression analysis), or mean satisfaction scores (7 with bed rest v
8 with control; difference �0.1, 95% CI �0.6 to +0.3; based on
regression analysis) after 12 weeks.
Harms: The subsequent RCT did not report on harms of bed rest.16
Comment: The regression analysis in the RCT adjusted odds ratios and differences
between treatments for several variables including baseline
differences in age, sex, presence or absence of paresis, disease
duration, and people�s history with respect to sciatica, among
others.16 We found one further systematic review (search date
1996) of bed rest and advice to stay active in people with acute low
back pain that found three RCTs that included people with sciatica
or radiating pain.17 However, no further details were given in the
review on the proportion of people in these RCTs with herniated
discs. The review concluded that there was little evidence on bed
rest specifically for herniated lumbar discs, although the RCTs they
did find questioned the efficacy of bed rest for sciatica.17
OPTION ADVICE TO STAY ACTIVE
One systematic review of conservative treatments for sciatica caused by
lumbar disc herniation found no RCTs on advice to stay active.
Benefits: We found one systematic review (search date 1998) of conservative
treatments for sciatica caused by disc herniation, which found no
RCTs of advice to stay active.13 We found no subsequent RCTs.
Harms: We found no RCTs.
Comment: None.
OPTION MASSAGE
One systematic review identified no RCTs of massage in people with
symptomatic lumbar disc herniation.
Benefits: We found one systematic review (search date 1998) of conservative
treatments for sciatica caused by disc herniation, which found no
RCTs of massage.13 We found no subsequent RCTs.
Harms: We found no systematic review or RCTs.
Comment: None.
OPTION HEAT OR ICE
One systematic review identified no RCTs of heat or ice for sciatica
caused by lumbar disc herniation.
Benefits: We found one systematic review (search date 1998) of conservative
treatments for sciatica caused by disc herniation, which identified
no RCTs on the use of heat or ice for herniated lumbar discs.13 We
found no subsequent RCTs.
Harms: We found no systematic review or RCTs.
Comment: None.
OPTION SPINAL MANIPULATION
One RCT identified by a systematic review in people with sciatica caused
by disc herniation found that spinal manipulation increased self perceived
improvement after 2 weeks compared with a placebo of infrequent
infrared heat. Another RCT identified by the review, comparing spinal
manipulation, manual traction, exercise, and corsets, found no significant
difference among groups in self perceived improvement after 1 month.
One subsequent RCT found that spinal manipulation increased the
proportion of people with improved symptoms compared with traction.
Concerns exist regarding possible further herniation from spinal
manipulation in people who are surgical candidates.
Benefits: We found two systematic reviews13,18 and one subsequent RCT.19
The first systematic review (search date 1998), which did not
perform meta-analysis, identified two RCTs of spinal manipulation
for sciatica caused by disc herniation.13 The second systematic
review (search date not reported) identified no RCTs.18 The first RCT
(207 people) included in the first review compared spinal manipulation
(every day if necessary) versus placebo (infrared heat 3 times
weekly).13 It found that spinal manipulation increased overall self
perceived improvement at 2 weeks compared with placebo (98/
123 [80%] with spinal manipulation v 56/84 [67%] with placebo;
RR 1.19, 95% CI 1.01 to 1.32; NNT 8, 95% CI 5 to 109).13 The
second included RCT (322 people) compared four interventions:
spinal manipulation, manual traction, exercise, and corsets, in a
factorial design.13 It found no significant difference among treatments
in overall self perceived improvement after 28 days (quantified
results not reported). The subsequent RCT (112 people with
symptomatic herniated lumbar disc) compared pulling and turning
manipulation versus traction.19 It found that significantly more
people were �improved� (absence of lumbar pain, improvement in
lumbar functional movement) or �cured� (absence of lumbar pain,
straight leg raising of >70�, ability to return to work) with spinal
manipulation compared with traction (54/62 [87%] with spinal
manipulation v 33/50 [66%] with traction; RR 1.32, 95% CI 1.06 to
1.65; NNT 5, 95% CI 4 to 16; timescale not reported).
Harms: The first systematic review did not report adverse effects.13 The
second systematic review identified one review of 135 case reports
of serious complications after spinal manipulation published
between 1950 and 1980.18 However, the frequency of these
effects was not certain. The case review attributed these complications
to cervical manipulation, misdiagnosis, presence of coagulation
dyscrasias, presence of herniated nucleus pulposus, or
improper techniques. The subsequent RCT found that two out of 60
people receiving traction had syncope; no adverse effects were
reported in people receiving manipulation.19 We found a third
systematic review (search date 2001, 5 prospective observational
studies).20 The largest study included in the review (4712 treatments
in 1058 people having both cervical and lumbar spinal
manipulations) found that the most common reaction was local
discomfort (53%), followed by headache (12%), tiredness (11%),
radiating discomfort (10%), dizziness (5 Confused

, nausea (4 Confused

, hot skin
(2 Confused

, and other complaints (2 Confused

. The incidence of serious adverse
effects is reported as rare, and is estimated from published case
series and reports to occur in one in 1�2 million treatments. The
most common of these serious effects were cerebrovascular accidents
(the total proportion of people having manipulations was not
reported and the rate of this adverse effect cannot be estimated).
However, it is difficult to assess whether such events are directly
related to treatment.
Comment: In the third review, which examined risks, the percentages include
both cervical and lumbar spinal manipulations, which may overestimate
the effect of lumbar spinal manipulations.20 The authors of
the review advise caution in interpreting these results, as they are
speculative and based on assumptions about the numbers of
manipulations performed and unreported cases. More reliable data
are needed on the incidence of specific risks. It is unclear whether
the populations studied in the RCTs cited included people who were
surgical candidates for disc herniation. Concerns exist regarding
possible further herniation from spinal manipulation in people who
are surgical candidates.
OPTION EXERCISE THERAPY
One systematic review of one RCT found no significant difference in
global improvement between isometric exercise and manual traction in
people with sciatica caused by disc herniation.
Benefits: We found one systematic review (search date 1998) of conservative
treatments for sciatica caused by disc herniation.13 The review
included one RCT (50 people) that compared isometric exercise
versus manual traction (both for 5�7 days; see comment below).
The review found no significant difference between groups in a
global measure of improvement (reported as no significant difference,
absolute numbers and P value not reported; see comment
below). We found no subsequent RCTs.
Harms: The review did not report on harms of exercise.13
Comment: The review did not report further details of treatment regimens. The
global measure of improvement was not further defined.13
OPTION ACUPUNCTURE
One systematic review found insufficient evidence on the effects of
acupuncture in people with herniated lumbar discs.
Benefits: We found one systematic review (search date 1998) in people with
back and neck pain, which identified one small RCT of acupuncture
in people with sciatica.21 The RCT (30 people with acute sciatica;
see comment below) compared acupuncture at electronically
detected non-traditional points versus sham acupuncture. The
review reported that the RCT found that acupuncture significantly
improved three outcomes compared with sham acupuncture and
reported that the RCT concluded that there was an overall benefit of
acupuncture.21 However, the review disagreed with the RCT�s overall
conclusion of benefit stating that it only found a significant
difference between groups in three out of 12 outcome measures,
and that there was no significant difference between acupuncture
and sham acupuncture in pain intensity at rest, the most clinically
relevant outcome, after 5 days (absolute numbers and P value not
reported).21 The review found one RCT in people with neck and
lumbar pain (see comment below).
Harms: No adverse effects from the two RCTs were reported in the systematic
review.21
Comment: In the RCT of people with acute sciatica, the acute sciatica may not
have been caused by disc herniation.21 The review also included
one small crossover RCT (42 people, radicular and pseudo radicular
cervical and lumbar pain owing to stenosis, herniated disc, or both)
that compared laser acupuncture at traditional points versus sham
laser acupuncture. The review found no significant difference
between groups in reduction of pain intensity after 24 hours,
although pain was significantly improved in the laser acupuncture
group at 15 minutes, 1 hour, and 6 hours compared with control.
The sample sizes in both RCTs included in the review were small and
provide little evidence of the effectiveness of acupuncture specifically
in people with herniated lumbar disc.
QUESTION What are the effects of surgery?
OPTION STANDARD DISCECTOMY
One RCT found that standard discectomy increased self reported
improvement at 1 year, but not at 4 and 10 years, compared with
conservative treatment (physiotherapy). Three RCTs found no significant
difference in clinical outcomes between standard discectomy and
microdiscectomy. Adverse effects were similar with both procedures. One
RCT found no significant difference in satisfaction or pain between
standard disectomy and video-assisted arthroscopic microdisectomy at
about 30 months, although post-operative recovery was slower with
standard disectomy.
Benefits: Versus conservative treatment: We found two systematic
reviews (search dates 199922 and not reported23) which included
the same RCT (126 people with symptomatic L5/S1 disc herniation)
24 comparing standard discectomyversus conservative treatment
(6 weeks of physiotherapy). Each person assessed and
graded their improvement in terms of pain and function into four
categories: �good� (completely satisfied), �fair�, �poor�, and �bad�
(completely incapacitated for work because of pain). The RCT found
that discectomy significantly increased the proportion of people
reporting their improvement as �good� after 1 year compared with
conservative treatment (intention to treat analysis: 39/60 [65.0%]
with surgery v 24/66 [36.4%] with conservative treatment;
RR 1.79, 95% CI 1.30 to 2.18; NNT 3, 95% CI 2 to 9). However, at
4 and 10 years, there was no significant difference in the same
outcome (at 4 years, AR for �good� improvement: 40/60 [66.7%]
with surgery v 34/66 [51.5%] with conservative treatment;
RR 1.29, 95% CI 0.96 to 1.56; at 10 years: 35/60 [58.3%] with
surgery v 37/66 [56.1%] with conservative treatment; RR 1.04,
95% CI 0.73 to 1.32). Versus microdiscectomy: One systematic
review (search date 1999)22 identified three RCTs (219 people)
comparing standard discectomy versus microdiscectomy. It did
not perform a meta-analysis because outcomes were not comparable.
The first RCT in the review (60 people with lumbar disc
herniation) found no significant difference between standard discectomy
and microdiscectomy in the proportion of people who rated
their operative outcome as �good�, �almost recovered�, or �totally
recovered� at 1 year (intention to treat analysis: 26/30 [87%] with
standard discectomy v 24/30 [80%] with microdiscectomy;
RR 1.08, 95% CI 0.78 to 1.20).25 It found no difference between
treatments in the change in preoperative and postoperative pain
scores (visual analogue scale; P value not reported) or in the
duration of time taken to return to work (both 10 weeks). The
second RCT in the review (79 people with lumbar disc herniation)
found no significant difference between microdiscectomy and
standard discectomy in pain in the legs or back (visual analogue
scale, not specified) or in analgesia use at any point during the 6
week follow up (absolute numbers not reported).26 The third RCT
(80 people) found that clinical outcomes and duration of sick leave
were similar at 15 months, but the review did not provide further
details.22 Versus video-assisted arthroscopic
microdiscectomy: See benefits of microdiscectomy.
Harms: Versus conservative treatment: The RCT included in both systematic
reviews did not report on complications of standard
discectomy.24 Versus microdiscectomy: One systematic review
reported that there was no significant difference between standard
discectomy and microdiscectomy in perioperative bleeding, duration
of stay, or scar tissue (numbers not reported).22 The first RCT
included in the review reported one person in each group with a
nerve root tear and, of the people having microdiscectomy, one had
a dural leak and one had suspected discitis.25 The second RCT
included in the review did not report on the complications of either
procedure.26 Complication rates were reported inconsistently in
studies, making it difficult to combine results to produce overall
rates. Rates of complications for all types of discectomy have been
compiled (see table 1, p 16).23
Comment: The RCT comparing standard discectomy versus conservative
treatment had considerable crossover between the two treatment
groups.24 Of 66 people randomised to receive conservative treatment,
17 received surgery; of 60 people randomised to receive
surgery, one refused the operation.24 The results presented above
are based on an intention to treat analysis. One systematic review of
published reports (search date not reported) found 99 cases of
vascular complications after lumbar disc surgery since 1965.27
Reported risk factors for vascular complications included: previous
disc or abdominal surgery leaving adhesions; chronic disc pathology
from disruption or degeneration of anterior annulus fibrosus and
anterior longitudinal ligament or peridiscal fibrosis; improper positioning
of the patient; retroperitoneal vessels and operated disc in
close proximity; and vertebral anomalies, such as hypertrophic
spurs compressing vessels during operation. The systematic review
did not state out of how many operations the 99 complications
arose from, therefore we can not estimate the incidence of adverse
vascular events from discectomy.27
OPTION MICRODISCECTOMY
We found no RCTs comparing microdiscectomy versus conservative
treatment. Three RCTs found no significant difference in clinical
outcomes between microdiscectomy and standard discectomy. One RCT
found no significant difference in satisfaction or pain between
video-assisted arthroscopic microdiscectomy and standard discectomy at
about 30 months, although postoperative recovery was slower with
standard discectomy. We found insufficient evidence on the effects of
automated percutaneous discectomy compared with microdiscectomy.
Benefits: We found no systematic review. Versus conservative treatment:
We found no RCTs. Versus standard discectomy: See benefits of
standard discectomy, p 10. Video-assisted arthroscopic
microdiscectomy versus standard discectomy: We found one
RCT (60 people with proved lumbar disc herniation and associated
radiculopathy after failed conservative treatment).28 It found no
significant difference between video-assisted arthroscopic discectomy
and standard discectomy in the proportion of people who
were �very satisfied� on a 4 point satisfaction scale after about 31
months (22/30 [73%] with microdiscectomy v 20/30 [67%] with
standard discectomy; RR 1.10, 95% CI 0.71 to 1.34). There was
also no significant difference in mean pain score (visual analogue
scale from 0 [no pain] to 10 [severe and incapacitating pain]: 1.2
with microdiscectomy v 1.9 with standard discectomy). However,
the mean duration of postoperative recovery was almost twice as
long with open surgery as with microdiscectomy (27 days with
microdiscectomy v 49 days with standard discectomy; P value not
reported). Versus automated percutaneous discectomy: See
glossary. See benefits of automated percutaneous discectomy,
p 13.
Harms: Video-assisted arthroscopic microdiscectomy versus open
discectomy: The RCT reported that one person having open
discectomy had leakage of spinal fluid from the dural sac 2 weeks
after the operation.28 No other postoperative complications or
neurovascular injuries were observed in either the standard
discectomy or the microdiscectomy groups. Complication rates
were reported inconsistently in studies, making it difficult to combine
results to produce overall rates. Rates of complications for all
types of discectomy have been compiled (see table 1, p 16).23
Comment: None.
We found no RCTs comparing automated percutaneous discectomy versus
either conservative treatment or standard discectomy. We found
insufficient evidence on the clinical effects of automated percutaneous
discectomy compared with microdiscectomy.
Benefits: Versus conservative treatment: We found no systematic review
or RCTs. Versus standard discectomy: One systematic review
(search date not reported) identified no RCTs comparing automated
percutaneous discectomy (APD) versus standard discectomy.23
Versus microdiscectomy: One systematic review (search date
1999) identified two RCTs that were not directly comparable
because there were differences in the equipment used.22 One RCT
(71 people with radiographical confirmation of disc herniation) was
stopped prematurely, after an interim analysis at 6 months found
that APD was associated with significantly lower success rate than
microdiscectomy (overall outcome was classified as �success� or
�failure� by the clinician and a masked observer [details not
reported]: 9/31 [29%] with APD v 32/40 [80%] with microdisectomy;
P<0.001).29 However, the other RCT (40 people with
radiographical confirmation of disc herniation) reported similar
improvements in the composite clinical score with APD and microdiscectomy
(scale 0�10, including back and leg pain, and sensory
and motor deficit) at 2 years (preoperative scores: 4.55 with APD v
4.20 with microdiscectomy; scores at 2 years: 8.23 with APD v
7.67 with microdiscectomy).30 More people in the APD group rated
their surgical outcomes as �excellent� or �good� than did those in
the microdiscectomy group 2 years after surgery (14/20 [70%] with
APD v 11/20 [55%] with microdiscectomy; P=0.33).
Harms: The systematic review found that re-operations for recurrent or
persistent disc herniations at the same level as the initial operations
were reported more frequently with APD compared with either
microdiscectomy or standard discectomy (APD 83%, 95%
CI 76% to 88% v microdiscectomy 64%, 95% CI 48% to 78% v
standard discectomy 49%, 95% CI 38% to 60%).23 The first RCT did
not report adverse effects.29 The second RCT reported that no
complications had occurred with APD, but did not comment on
whether there had been any complications in the microdiscectomy
group.30 The mean duration of recovery after surgery was longer in
people who had microdiscectomy compared with those who had
APD (mean weeks of postoperative recovery [range]: 22.9 weeks
[4 weeks to 1 year] with microdiscectomy v 7.7 weeks [1�26
weeks] with APD). Complication rates were reported inconsistently
in studies, making it difficult to combine results to produce overall
rates. Rates of complications for all types of discectomy have been
compiled (see table 1, p 16).23
Comment: None.
OPTION LASER DISCECTOMY
We found no systematic review or RCTs on the use of laser discectomy
for treatment of people with symptomatic herniated lumbar discs.

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