Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica due to lumbar disc herniation

We read with great interest the Article published by Martin Wilby and colleagues 1 Wilby MJ Best A Wood E et al. Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluation. Lancet Rheumatol. 2021; 3: e347-e356 Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar that evaluated the clinical and cost-effectiveness of transforaminal epidural steroid injection (TFESI) compared with surgical microdiscectomy for sciatica secondary to uncomplicated lumbar disc herniation. In their pragmatic, phase 3, multi-centre, open-label, randomised trial, Wilby and colleagues found that the improvement in the Oswestry Disability Questionnaire score at 18 weeks (the primary outcome) was similar between the two groups, and that surgery had a low probability (0·17) of being cost-effective. The authors recommended that TFESI should be the first-line invasive treatment option for patients with uncomplicated sciatica secondary to herniated lumbar disc with a symptom duration of up to 12 months who had failed conservative management. I wish to applaud the authors for this landmark study that, for the first time, provides class 1 evidence regarding the effectiveness of TFESI in patients with sciatica. However, some concerns need to be addressed. Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluationFor patients with sciatica secondary to herniated lumbar disc, with symptom duration of up to 12 months, TFESI should be considered as a first invasive treatment option. Surgery is unlikely to be a cost-effective alternative to TFESI. Full-Text PDF Open AccessSurgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica due to lumbar disc herniation – Authors' replyWe thank Vivek Tiwari for their interest in our Article.1 The surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES) trial represents a real-world snapshot of patients that required treatment for unremitting sciatica secondary to herniated lumbar disc within the UK. Herniated lumbar disc size was recorded by the treating specialist but no validation was made of the subjective, surgeon-rated assessment of these data. Full-Text PDF