Surgery vs Epidural Steroid Injection for Sciatica Secondary to Herniated Lumbar Disc

Sarfaroj Khan 


March 25, 2021


  • The use of transforaminal epidural steroid injection (TFESI) as the initial invasive treatment was similarly effective to surgical microdiscectomy (SM) at reducing pain and disability for sciatica secondary to herniated lumbar disc, with symptom duration between 6 weeks and 12 months.

  • SM was unlikely to be a cost-effective alternative to TFESI and was associated with higher incidence of adverse events (AEs).

Why this matters

  • Given the safety of TFESI, along with unlikely cost-effectiveness of surgery as the initial invasion treatment, physicians should consider the use of TFESI as a first invasive treatment option for uncomplicated sciatica with symptom duration of up to 12 months.

Study details

  • NERVES was a multicentre, open label, randomised controlled trial of 163 patients with non-emergency sciatica secondary to herniated lumbar disc with symptoms of ≤12 months and leg pain that was unresponsive to non-invasive management.

  • Patients were randomly assigned to receive TFESI (n=80) or SM (n=83).

  • Primary outcome: Oswestry Disability Questionnaire (ODQ) score at 18 weeks.

  • Funding: National Institute for Health Research.

Key results

  • ODQ scores changed from 49.39 and 53.74 at baseline to 22.30 and 30.02 at week 18, with a mean improvement of 26.74 and 24.52 points in the SM and TFESI groups, respectively.

  • At week 18, ODQ scores did not differ significantly between groups (estimated treatment difference, −4.25; 95% CI, 11.09 to 2.59; P=.22).

  • AEs were observed in 14% and 4% of patients in the SM and TFESI groups, respectively, with 4 serious AEs in the SM group vs none in the TFESI group.

  • Compared with TFESI, SM had an incremental cost-effectiveness ratio of £38,737 per quality-adjusted life-year (QALY) gained, and a 0.17 probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY.


  • Open-label design

  • Treatment crossover.

  • More than 10% data were missing for primary outcome.


Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, Wheatley D, Hill-McManus D, Sharma M, Clark S, Baranidharan G, Price C, Mannion R, Hutchinson PJ, Hughes DA, Marson A, Williamson PR. 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 Mar 18 [Epub ahead of print]. doi: 10.1016/S2665-9913(21)00036-9.  View full text 

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.


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