NERVES

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

Wilby MJ, Best A, Wood E, et al. The Lancet. Rheumatology 2021 · PMID 33969319 · doi:10.1016/s2665-9913(21)00036-9

Question

For sciatica from lumbar disc herniation, is transforaminal epidural steroid injection as effective as microdiscectomy as first-line invasive treatment?

Design

NIHR-funded pragmatic multicentre open-label phase 3 RCT with economic evaluation in 11 UK spinal units.

Patients

Adults aged 16-65 with MRI-confirmed, non-emergency sciatica from lumbar disc herniation of 6 weeks to 12 months duration, not responding to non-invasive care.

Intervention

Transforaminal epidural steroid injection

Comparison

Surgical microdiscectomy

Primary outcome

Oswestry Disability Index at 18 weeks

Key result

Disability at 18 weeks did not differ significantly between injection and microdiscectomy, and injection was the cheaper first-line option on economic evaluation.

Limitations

Open-label, only a small fraction of screened patients were enrolled, and primary outcome data were missing for a proportion of each arm.

Impact on practice

Supports offering transforaminal epidural injection before microdiscectomy in the NHS sciatica pathway for patients without red flags.