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Low Back Pain and Sciatica in Over 16S: Assessment and Management

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Low Back Pain and Sciatica in Over 16S: Assessment and Management National Institute for Health and Care Excellence Final Low back pain and sciatica in over 16s: assessment and management [A] Evidence review for pharmacological management of sciatica NICE guideline NG59 Evidence review underpinning recommendations 1.2.16 to 1.2.21 and research recommendations in the NICE guideline September 2020 . This evidence review was developed by the National Guideline Centre FINAL .Error! No text of specified style in document. Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2020. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-2188-1 FINAL . Contents 1 Pharmacological management of sciatica ...................................................................... 6 1.1 Review question ....................................................................................................... 6 1.1 Introduction ............................................................................................................... 6 1.1.2 Summary of the protocol ........................................................................................ 6 1.1.3 Methods and process ............................................................................................ 8 1.1.4 Effectiveness evidence .......................................................................................... 9 1.1.4.1 Included studies ......................................................................................... 9 1.1.4.2 Excluded studies ....................................................................................... 9 1.1.5 Summary of studies included in the effectiveness evidence ......................... 9 1.1.6 Summary of the effectiveness evidence ..................................................... 13 1.1.7 Economic evidence.............................................................................................. 20 1.1.7.1 Included studies ....................................................................................... 20 1.1.7.2 Excluded studies ..................................................................................... 20 1.1.8 Summary of included economic evidence ................................................... 20 1.1.9 Economic model ......................................................................................... 20 1.1.10 Evidence statements ......................................................................................... 20 1.1.11 The committee’s discussion and interpretation of the evidence.......................... 20 1.1.11.1. The outcomes that matter most ............................................................ 20 1.1.11.2 The quality of the evidence .................................................................... 20 1.1.11.3 Benefits and harms ................................................................................ 21 1.1.11.4 Cost effectiveness and resource use ..................................................... 24 1.1.12 Recommendations supported by this evidence review .............................. 25 References ......................................................................................................................... 26 Appendices ........................................................................................................................ 36 Appendix A – Review protocol .................................................................................. 36 Appendix B – Literature search strategies ............................................................... 47 B.1 Clinical search literature search strategy ................................................................. 47 B.2 Health Economics literature search strategy ........................................................... 54 Appendix C – Effectiveness evidence study selection ............................................ 61 Appendix D – Effectiveness evidence ....................................................................... 62 Appendix E – Forest plots ......................................................................................... 89 E.1 Non-steroidal anti-inflammatory drugs compared to placebo ................................ 89 E.2 Benzodiazepines compared to placebo .................................................................... 89 E.3 Gabapentinoids compared to placebo ...................................................................... 90 E.4 Corticosteroids compared to placebo ...................................................................... 94 E.5 Corticosteroids compared to gabapentinoids .......................................................... 97 Appendix F – GRADE tables ...................................................................................... 99 4 FINAL . Appendix G – Economic evidence study selection ................................................ 104 Appendix H – Economic evidence tables ............................................................... 105 Appendix I – Health economic model .................................................................... 106 Appendix J – Excluded studies............................................................................... 107 Clinical studies .................................................................................................. 107 Health Economic studies ................................................................................... 110 Appendix K – Research recommendations – full details ....................................... 111 K.1.1 Research recommendation............................................................................. 111 K.1.2 Why this is important ...................................................................................... 111 K.1.3 Rationale for research recommendation ....................................................... 111 K.1.4 Modified PICO table ........................................................................................ 111 K.1.5 Research recommendation............................................................................. 112 K.1.6 Why this is important ...................................................................................... 112 K.1.7 Rationale for research recommendation ....................................................... 112 K.1.8 Modified PICO table ........................................................................................ 113 5 FINAL Low back pain and sciatica 1 Pharmacological management of sciatica 1.1 Review question What is the clinical and cost effectiveness of pharmacological treatment in the management of sciatica? 1.1 Introduction Sciatica is a general term for pain in the leg as a result of nerve compression or irritation in the lumbar spine. This is sometimes referred to as radicular pain. Many people with low back pain have referred pain in the leg, without nerve compression. The commonest cause is impingement or inflammation of the lumbosacral nerve roots and is frequently associated with herniation of a lumbar intervertebral disc. In older people, additional anatomical changes may be important. Anatomical structures and abnormal movement in the back can also cause pain to be felt or ‘referred’ to the leg. It can be difficult to differentiate referred pain from sciatica, and the two may co-exist. The pharmacological management of back pain, including referred pain, was included in ‘Low back pain and sciatica in over 16s: assessment and management’ (NG59). People with sciatica typically have severe pain at onset and a slower and less complete recovery than people with back pain without sciatica. A review of pharmacological interventions for sciatica is important because people with sciatica commonly present in primary care. Drugs for neuropathic pain are frequently prescribed for sciatica in addition to opioids and other analgesics. There is high variability of prescribing volumes between CCGs and different population groups. A significant proportion of people continue taking medication for sciatica in the longer term. When NG59 was first published in 2016, the guideline cross-referenced ‘Neuropathic
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