ArticleThe Lancet. Rheumatology2021
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.
Article in The Lancet. Rheumatology, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT06956664 (Comparative Efficacy of Physiotherapeutic Exercise Regimens Implemented After Caudal Epidural Steroid Injection), which is not on this map. Cited by 36 papers, 2 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Comparative Efficacy of Physiotherapeutic Exercise Regimens Implemented After Caudal Epidural Steroid Injection
Who cites it
36 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- The Implementation of Persistent Spinal Pain Syndrome (PSPS): Mechanism-Based Recommendations.Pain practice : the official journal of World Institute of Pain · 2026Guideline
- Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials.BMJ (Clinical research ed.) · 2023Pooled it
- No Efficacy of Dexamethasone Injections for Acute Sciatica: A Double-Blind Randomized Study Versus Saline.European journal of pain (London, England) · 2026Trial
- CT-guided Pulsed Radiofrequency Combined with Steroid Injection for Sciatica from Herniated Disk: A Randomized Trial.Radiology · 2023Trial
- SupraneuralBJA open · 2023Trial
- Enhanced Delivery of Transforaminal Epidural Steroid Injection (TFESI) for Radiculopathy Associated with Acute Lumbar Disc Prolapse Through Physiotherapist-led Assessment, Consent, and Direct Listing.Anesthesiology and pain medicine · 2026Article
- Effect of Intraoperative Epidural Steroid in Early Outcomes After Full-Endoscopic Lumbar Discectomy - A Randomized Controlled Trial.Global spine journal · 2026Article
- Ultrasound-guided selective nerve root blocks and caudal epidural injection in the management of lumbar radicular syndrome: a case series with one-year follow-up.Journal of ultrasound · 2026Article
- Interpretable prediction of prolonged length of stay for patients undergoing lumbar disc herniation surgery based on machine learning and SHAP.BMC health services research · 2026Article
- A systematic review and meta-analysis on surgery for lumbar disc herniation: optimal timing of surgery, return to work and outcomes compared with conservative management.Brain & spine · 2026Article
- Methodological Concerns Regarding the Interpretation of Transforaminal Epidural Steroid Injection Efficacy for Lumbar Radicular Pain [Letter].Journal of pain research · 2026Article
- Efficacy Of Transforaminal Epidural Steroid Injections in Lumbar Radicular Pain.Journal of pain research · 2026Article
- Transforaminal Epidural Steroid Injection Technique: Fluoroscopy-Guided Minimally Invasive Injection for Lower Limb Radiculopathy-Twelve Golden Steps.The Indian journal of radiology & imaging · 2026Article
- Article
- A qualitative study of experiencing cauda equina syndrome and its aftercare in the UK.Spinal cord · 2025Article
- Is out-of-hours decompression for acute lumbar disc herniation associated with greater peri-operative complications? A tertiary centre, retrospective cohort study.European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society · 2025Article
- Evidence-Based Clinical Practice Guidelines for Patients With Lumbar Disc Herniation With Radiculopathy in South Korea.Neurospine · 2025Article
- Prognostic factors of selective nerve root block under fluoroscopic guidance for the treatment of young patients with lumbar disc herniation and its role in preventing surgery.Journal of orthopaedic surgery and research · 2025Observational
- CONSORT 2025 explanation and elaboration: updated guideline for reporting randomised trials.BMJ (Clinical research ed.) · 2025Article
- Article
Corrections and comments
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Authors and funding
17 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe optimal invasive treatment for sciatica secondary to herniated lumbar disc remains controversial, with a paucity of evidence for use of non-surgical treatments such as transforaminal epidural steroid injection (TFESI) over surgical microdiscectomy. We aimed to investigate the clinical and cost-effectiveness of these options for management of radicular pain secondary to herniated lumbar disc.
methodsWe did a pragmatic, multicentre, phase 3, open-label, randomised controlled trial at 11 spinal units across the UK. Eligible patients were aged 16-65 years, had MRI-confirmed non-emergency sciatica secondary to herniated lumbar disc with symptom duration between 6 weeks and 12 months, and had leg pain that was not responsive to non-invasive management. Participants were randomly assigned (1:1) to receive either TFESI or surgical microdiscectomy by an online randomisation system that was stratified by centre with random permuted blocks. The primary outcome was Oswestry Disability Questionnaire (ODQ) score at 18 weeks. All randomly assigned participants who completed a valid ODQ at baseline and at 18 weeks were included in the analysis. Safety analysis included all treated participants. Cost-effectiveness was estimated from the EuroQol-5D-5L, Hospital Episode Statistics, medication usage, and self-reported resource-use data. This trial was registered with ISRCTN, number ISRCTN04820368, and EudraCT, number 2014-002751-25.
findingsBetween March 6, 2015, and Dec 21, 2017, 163 (15%) of 1055 screened patients were enrolled, with 80 participants (49%) randomly assigned to the TFESI group and 83 participants (51%) to the surgery group. At week 18, ODQ scores were 30·02 (SD 24·38) for 63 assessed patients in the TFESI group and 22·30 (19·83) for 61 assessed patients in the surgery group. Mean improvement was 24·52 points (18·89) for the TFESI group and 26·74 points (21·35) for the surgery group, with an estimated treatment difference of -4·25 (95% CI -11·09 to 2·59; p=0·22). There were four serious adverse events in four participants associated with surgery, and none with TFESI. Compared with TFESI, surgery had an incremental cost-effectiveness ratio of £38 737 per quality-adjusted life-year gained, and a 0·17 probability of being cost-effective at a willingness-to-pay threshold of £20 000 per quality-adjusted life-year.
interpretationFor 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.
fundingHealth Technology Assessment programme of the National Institute for Health Research (NIHR), UK.
Identifiers
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.