Rédacteurs : Johan Nguyen, Olivier Goret, Claude Pernice, Jean-Luc Gerlier, Henri Truong

Sommaire

Sciatica

Sciatique : évaluation de l'acupuncture

Articles connexes: - conduites thérapeutiques - pathologies - qigong - acupuncture expérimentale -

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture.
☆☆ Evidence for effectiveness of acupuncture.
☆ Evidence for effectiveness of acupuncture mais limitées qualitativement et/ou quantitativement.
Ø No evidence or insufficient evidence.

1.1. Generic Acupuncture

1.1.1. Zhang 2023 ☆☆

Zhang Z, Hu T, Huang P, Yang M, Huang Z, Xia Y, Zhang X, Zhang X, Ni G. The efficacy and safety of acupuncture therapy for sciatica: A systematic review and meta-analysis of randomized controlled trails. Front Neurosci. 2023 Feb 9;17:1097830. https://doi.org/10.3389/fnins.2023.1097830.

Background and objective Sciatica is a common type of neuropathic pain disease which poses a huge financial burden to the patient. For patients with sciatica, acupuncture has been recommended as an effective method for pain relief, while there is currently a lack of sufficient evidence to support its efficacy and safety. In this review, we aimed to critically assess the published clinical evidence on the efficacy and safety of acupuncture therapy for treating sciatica.
Methods An extensive literature search strategy was established in seven databases from their inception to 31 March 2022. Two independent reviewers performed the literature search, identification, and screening. Data extraction was performed on studies that meet the inclusion criteria, and a further quality assessment was performed according to the Cochrane Handbook and Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) recommendations. Summary Risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence interval (CI) were calculated using the fixed-effects or the random-effects model. Heterogeneity in effect size across studies was explored using the subgroup analysis and the sensitivity analysis. The quality of evidence was estimated following the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.
Results A total of 30 randomized controlled trials (RCTs) involving 2,662 participants were included in the meta-analysis. The results of the integration of clinical outcomes showed that the clinical efficacy of acupuncture was superior to that of medicine treatment (MT) in improving the total effective rate (relative risk (RR) = 1.25, 95% confidence interval (CI) [1.21, 1.30]; moderate certainty of evidence), reducing the Visual Analog Scale (VAS) pain score (standardized mean difference (SMD) = -1.72, 95% CI [-2.61, -0.84]; very low certainty of evidence), increasing pain threshold (SMD = 2.07, 95% CI [1.38, 2.75]; very low certainty of evidence), and decreasing recurrence rate (RR = 0.27, 95% CI [0.13, 0.56]; low certainty of evidence). In addition, a few adverse events (RR = 0.38, 95% CI [0.19, 0.72]; moderate certainty of evidence) were reported during the intervention, which indicated that acupuncture was a safe treatment option.
ConclusionsAcupuncture therapy is an effective and safe treatment for patients with sciatica, and it can be considered a suitable replacement for medicine treatment (MT). However, given the high heterogeneity and a low methodological quality of previous studies, future RCTs should be well-designed according to the rigorous methodology.

1.1.2. Han 2022

Han KH, Cho KH, Han C, Cui S, Lin L, Baek HY, Kim J. The effectiveness and safety of acupuncture treatment on sciatica: A systematic review and meta-analysis. Complement Ther Med. 2022 Dec;71:102872. https://doi.org/10.1016/j.ctim.2022.102872

Background Sciatica results from primary or secondary damage to the sciatic nerve in the lumbar or gluteal region. The first option for sciatica is analgesics, but their therapeutic effect and safety in long-term use are questionable. On the other hand, acupuncture has recently been recognized as a complementary and alternative medicine (CAM) to conventional medicine, and studies on its effectiveness and safety have been actively conducted.
ObjectiveTo systematically compare acupuncture with analgesics in terms of effect, safety, and durability in the treatment of sciatica METHODS: This review was performed in accordance with Cochrane Handbook for Systematic Reviews of Interventions Version 6.2. Four databases were searched for this review: Wangfang, the Korean Traditional Knowledge Portal (KTKP), PubMed, and EBSCOhost. The primary outcome measures in the review were total effective rate (TER), visual analog scale (VAS) score and pain threshold, and the secondary ones were adverse effects (AEs) and relapse rates. Risk ratio (RR) for TER and mean difference (MD) for VAS score and pain threshold were used as statistics for the meta-analysis of effectiveness, along with associated 95 % confidence intervals (CIs) and P-values. AEs and relapse rates were used for the safety and durability of the interventions. Version 2 of the Cochrane risk-of-bias assessment tool for randomized trials (RoB 2) was used for the methodological quality of randomized controlled trials (RCTs) included in the review.
ResultsThe synthesized TER of 28 RCTs involving 2707 participants was significantly higher in the acupuncture group compared to the analgesic group (RR [95 % CI] = 1.20 [1.16, 1.24], P < 0.001). The synthesized VAS score of 7 RCTs involving 589 participants was significantly reduced in the acupuncture group compared to the analgesic group (MD [95 % CI] = - 1.78 [- 2.44, - 1.12], P < 0.001). In 5 RCTs involving 311 participants, the synthesized pain threshold was significantly elevated in the acupuncture group compared to the analgesic group (MD [95 % CI] = 0.93 [0.64, 1.22], P < 0.001). Additionally, adverse effects (AEs) and relapse rates of RCTs in the review were lower in the acupuncture group compared to the analgesic group.
ConclusionIn this systematic review, acupuncture treatment was significantly effective and safe compared to analgesics in sciatica. In the future, studies with a rigorous study design are required to increase the validity of the effectiveness and safety of acupuncture treatment for sciatica.

1.1.3. Ji 2015 ★★

Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:192808. doi: 10.1155/2015/192808. [183273]

Purpose This study aims to assess the effectiveness of acupuncture therapy for sciatica.
Methods Comprehensive searches of 8 databases were conducted up until April 2015. Outcomes included effectiveness (proportion of patients who improved totally or partly in clinical symptoms), pain intensity, and pain threshold. Effect sizes were presented as risk ratio (RR) andmean difference (MD). Pooled effect sizes were calculated by fixed effects or randomeffects model.
Results A total of 12 studies (involving 1842 participants) were included. Results showed that acupuncture was more effective than Conventional Western medicine (CWM) in outcomes effectiveness (RR 1.21, 95% CI: 1.16–1.25), pain intensity (MD −1.25, 95% CI:−1.63 to −0.86), and pain threshold (MD: 1.08, 95% CI: 0.98–1.17). Subgroup and sensitivity analysis found that the results did not change in different treatment method and drug categories substantially. The reported adverse effects were acceptable.
Conclusion Acupuncture may be effective in treating the pain associated with sciatica.

1.1.4. Qin Z 2015 ★

Qin Z, Liu X, Wu J, Zhai Y, Liu Z. Effectiveness of Acupuncture for Treating Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:425108. doi: 10.1155/2015/425108.[184934]

Purpose This is a systematic review and meta-analysis, which aimed to assess the current evidence on the effects and safety of acupuncture for treating sciatica.
Methods In this review, a total of 11 randomized controlled trials were included.
Results As a result, we found that the use of acupuncture may be more effective than drugs and may enhance the effect of drugs for patients with sciatica.
Conclusion In conclusion, the results of this systematic review suggest that the use of acupuncture may more effectively relieve leg pain/lumbago and improve global assessment of sciatica when compared with NSAID (ibuprofen, meloxicam, and diclofenac) treatment. But because of the insufficient number of relevant and rigorous studies, the evidence is limited.

1.1.5. Lewis 2015 ★★

Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015 Jun 1;15(6):1461-77.[170143]

Purpose To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.
Methods We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.
Results We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.
Conclusion The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction.

1.1.6. Han 2014 ★

Han Chao, Sun Zhongren, Yue Jinhuan, Zhang Qinhong, Wang Delong. [Clinical efficacy on acupuncture on patients with sciatica: a systematic review]. Liaoning Journal of Traditional Chinese Medicine. 2014;2:324-326.[187038].

ObjectiveTo evaluate the clinical effect of sciatica with acupuncture and provide ideas and reference for making clinical decision.
MethodsThe databases of Pubmed, CNKI, Wanfang, CBM, Science Paper Online and Cochrane Library were searched and 878 related articles were found. Clear NPT system was used to evaluate the quality of the included studies, 19 RCTs (2521 Participants) were finally selected to find out the clinical efficacy of acupuncture of sciatica at home and abroad.
ResultsAnalysis obtained from the final literature included 19 pieces of paper (2521 Participants). The acupuncture treatment of sciatica at home and abroad has some clinical effect. But there is lack of strong evidence to confirm due to the incorporation comprehensive experimental quality limit.
ConclusionLarge sample, multi-center, high-quality trail RCTs are needed to conform the clinical efficacy of acupuncture therapy on sciatica.

1.1.7. Lewis 2011 ★

Lewis R, Williams N, Matar H, Din N, Fitzsimmons D, Phillips C, Jones M, Sutton A, Burton K, Nafees S, Hendry M, Rickard I, Chakraverty R, Wilkinson C. The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model. Health Technol Assess. 2011;15(39):1-578. [86704]

Objectifs Sciatica is a symptom characterised by well-localised leg pain with a sharp, shooting or burning quality that radiates down the back of the leg and normally to the foot or ankle. It is often associated with numbness or altered sensation in the leg. To determine the clinical effectiveness and cost-effectiveness of different management strategies for sciatica.
Méthodes Data sources: Major electronic databases (e.g. MEDLINE, EMBASE and NHS Economic Evaluation Database) and several internet sites including trial registries were searched up to December 2009. Review methods: Systematic reviews were undertaken of the clinical effectiveness and cost-effectiveness of different treatment strategies for sciatica. Effectiveness data were synthesised using both conventional meta-analyses and mixed treatment comparison (MTC) methods. An economic model was then developed to estimate costs per quality-adjusted life-year gained for each treatment strategy.
Résultats The searches identified 33,590 references, of which 270 studies met the inclusion criteria and 12 included a full economic evaluation. A further 42 ongoing studies and 93 publications that could not be translated were identified. The interventions were grouped into 18 treatment categories. A larger number of studies evaluated invasive interventions and non-opioids than other non-invasive interventions. The proportion of good-quality studies for each treatment category ranged from 0% to 50%. Compared with studies of less invasive interventions, studies of invasive treatments were more likely to confirm disc herniation by imaging, to limit patients included to those with acute sciatica (< 3 months' duration) and to include patients who had received previous treatment. The MTC analyses gave an indication of relative therapeutic effect. The statistically significant odds ratios of global effect compared with inactive control were as follows: disc surgery 2.8, epidural injection 3.1, chemonucleolysis 2.0 and non-opioids 2.6. Disc surgery and epidural injections were associated with more adverse effects than the inactive control. There was some evidence for the effectiveness of biological agents and acupuncture. Opioid medication and activity restriction were found to be less effective than the comparator interventions and opioids were associated with more adverse effects than the inactive control. The full economic evaluations were of reasonable to good quality, but were not able to fully address our research question. Although individual studies raised a number of important issues, it was difficult to draw meaningful conclusions across studies because of their heterogeneity. The economic model demonstrated that stepped-care approaches to patient management were likely to be cost-effective, relative to strategies that involved direct referral to disc surgery. Limitations: The limited number of studies for some comparisons, the high level of heterogeneity (within treatment comparisons) and the potential inconsistency (between treatment comparisons) weaken the interpretation of the MTC analyses.
Conclusions These findings provide support for the effectiveness of currently used therapies for sciatica such as non-opioid medication, epidural corticosteroid injections and disc surgery, but also for chemonucleolysis, which is no longer used in the UK NHS. These findings do not provide support for the effectiveness of opioid analgesia, which is widely used in this patient group, or activity restriction. They also suggest that less frequently used treatments, such as acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be effective. Stepped-care approaches to treatment for patients with sciatica are cost-effective relative to direct referral for surgery. Future research should include randomised controlled trials with concurrent economic evaluation of biological agents and acupuncture compared with placebo or with currently used treatments. Development of alternative economic modelling approaches to assess relative cost-effectiveness of treatment regimes, based on the above trial data, would also be beneficial.

1.1.8. Luijsterburg 2007 Ø

Liujterbrug PA et al. Effectiveness of conservative treatments for the lumbosacral radical syndrome; a systematic review. Eur Spine J. 2007;16(7):881-899.[145428].

Purpose To assess the effectiveness of conservative treatments of the lumbosacral radicular syndrome (sciatica).
Methods Relevant electronic databases and the reference lists of articles up to May 2004 were searched. Randomised clinical trials of all types of conservative treatments for patients with the lumbosacral radicular syndrome selected by two reviewers. Two reviewers independently assessed the methodological quality and the clinical relevance. Because the trials were considered heterogeneous we decided not to perform a meta-analysis but to summarise the results using the rating system of levels of evidence.
Results Thirty trials were included that evaluated injections, traction, physical therapy, bed rest, manipulation, medication, and acupuncture as treatment for the lumbosacral radicular syndrome. Because several trials indicated no evidence of an effect it is not recommended to use corticosteroid injections and traction as treatment option. Whether clinicians should prescribe physical therapy, bed rest, manipulation or medication could not be concluded from this review.
Conclusion At present there is no evidence that one type of treatment is clearly superior to others, including no treatment, for patients with a lumbosacral radicular syndrome.

1.1.9. Wang 2007

Wang Fan, Zhang Tong, Liu Yi. [Systematic review of acupuncture and moxibustion treatment of sciatica]. 针灸治疗坐骨神经痛的系统. World Chinese Medicine. 2007;2(6):354-5. [169232].

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Danish Health and Medicines Authority (DHMA, Danemark 2018) Ø

Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75. [195990].. {National Clinical Guideline: interventions for recent onset lumbar radiculopathy Danish Health Authority]. 2016 [193124].

Guidelines recommend against acupuncture.

2.2. Philippine Academy of Rehabilitation Medicine (PARM) 2017 ⊕

Low back pain management guideline. Philippine Academy of Rehabilitation Medicine (PARM). 2017:294P. [198246].

Acute low back pain with radiculopathy: There is some evidence to use acupuncture in acute low back pain with radiculopathy. PARM Endorses use of acupuncture as treatment for low back pain with radiculopathy.

2.3. Danish Health Authority (DHA, Denmark) 2016 ∅

National clinical guideline for the nonsurgical treatment of recent onset lumbar nerve root compression (lumbar radiculopathy) quick guide. Danish Health Authority. 2016;:. [208649]. URL

It is not good practice to offer acupuncture on a routine basis to patients with recent onset lumbar nerve root Compression.

2.4. National Institute for Health and Clinical Excellence (NICE, UK) 2016 Ø

National Institute for Health and Clinical Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). Evidence-based recommendations on assessing and managing low back pain and sciatica in people aged 16 and over London (UK): National Institute for Health and Clinical Excellence (NICE). 2016. [158090]. Données relatives à l'acupuncture : [158090-b].

1.2.8, Do not offer acupuncture for managing low back pain with or without sciatica.

2.5. North American Spine Society (NASS) 2014) Ø

Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S et al ; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180-91. [200343].

Question 15: what is the role of ancillary treatments such as bracing, electrical stimulation, acupuncture, and transcutaneous electrical stimulation in the treatment of lumbar disc herniation with radiculopathy? There is an insufficient evidence to make a recommendation for or against the use of ultrasound or low-power laser in the treatment of lumbar disc herniation with radiculopathy [40]. Grade of recommendation: I (insufficient evidence).

2.6. Accident Compensation Corporation (ACC, New-Zealand) 2011 Ø

Hardaker N, Ayson M. Pragmatic Evidence Based Review. The efficacy of acupuncture in the management of musculoskeletal pain. Accident Compensation Corporation (ACC, New-Zealand). 2011. [182414].

There is no evidence to recommend the use of acupuncture for lumbar disc herniation related radiculopathy (LDHR)

2.7. Philippine Academy of Rehabilitation Medicine (PARM, Philippine) 2011 ⊕

Clinical Practice Guidelines on the Diagnosis and Management of Low Back Pain. Philippine Academy of Rehabilitation Medicine (PARM). 2011. [199237]. Voir rappel des recommandations 2011 dans : Low back pain management guideline. Philippine Academy of Rehabilitation Medicine (PARM). 2017:294P. [198246].

There is some evidence to use acupuncture in acute low back pain with radiculopathy (Low Volume – Current)

2.8. Instituto di Recovero e Cura a Caraterre Scientifico (IRCCS, Italia) 2006 Ø

Negrini S, Giovannoni S, Minozzi S, Barneschi G, Bonaiuti D, Bussotti A, D'Arienzo M, Di Lorenzo N, Mannoni A, Mattioli S, Modena V, Padua L, Serafini F, Violante FS. Diagnostic therapeutic flow-charts for low back pain patients: the Italian clinical guidelines. Eura Medicophys. 2006;42(2):151-70. [199104].

Treatment of Low back pain patient. Physical therapies: acupuncture is not effective (strenght of evidence : A).
Treatment of sciatica patient. Physical therapies: acupuncture is not effective (strenght of evidence : A).

3. Randomized Controlled Trials

3.1. Sources

  • a = Ji 2015: Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:192808. [183273]
  • b = Qin 2015: Qin Z, Liu X, Wu J, Zhai Y, Liu Z. Effectiveness of Acupuncture for Treating Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:425108. [184934]
  • c = Lewis 2015: Lewis R, Williams N, Matar H, Din N, Fitzsimmons D, Phillips C, Jones M, Sutton A, Burton K, Nafees S, Hendry M, Rickard I, Chakraverty R, Wilkinson C. The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model. Health Technol Assess. 2011;15(39):1-578. [86704]

3.2. List

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  2. Zhan WZ, Liang W. Different methods for the treatment of 2100 cases of sciatica. Journal of GanSu College of TCM. 1993;10(2):47.(a)
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  5. Zhao RH. [Clinical study of electro-acupuncture onHuangtiao point to treat sciatica]. Unpublished data, 2004.(b)
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  7. Dong QJ, Wu BH, Zhang YM. Observation on the therapeutic effect of searching-needling method of acupuncture for 60 cases of primary sciatica. New Medical Science. 2008;7(4):135–136.(a)
  8. Wang XG. [Clinical study of acupuncture for treating 52 cases of lumber intervertebral disc herniation]. Asia-Pacific Traditional Medicine. 2008;4(9):39–40.(b)
  9. Zhang BM, Wu YC, Shao P, Shen J, Jin RF. [Electroacupuncture therapy for lumbar intervertebral disc protrusion: a randomized controlled trial]. Journal of Clinical Rehabilitative Tissue Engineering Research. 2008;12(2);353–355.(b)
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  11. Du Z, Shao P, He YH. [Clinical observation on 32 cases of lumber intervertebral disc herniation treated by electroacupuncture on Huatuo Jiaji points]. Journal of Traditional Chinese Medicine. 2009;50(7):617–619.(b)
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  13. Hu ZC, Shen LH, Wu YC. [Observations on the therapeutic effect of electro-acupuncture on lumbar intervertebral disc herniation]. Shanghai Journal of Acupuncture and Moxibustion. 2010;29(11):722–724.(b)
  14. Zhu JH, Chen HY, Chen JY. Treating 30 cases of backbone of sciatica by hip three-needle-based acupuncture. Clinical Journal of Chinese Médicine. 2011;3(5).78–79.(a)
  15. Zhang Z. Clinical observation of 145 cases of sciatica treated by acupuncture. Chinese Journal of Modern Drug Application. 2012;6(4).124–125.(a)
  16. Liu BL. Clinical analysis of 80 cases of acupuncture and moxibustion for treatment of sciatica. Guide of China Médicine. 2012;10(24):590–591.(a)
  17. Zeng YY. [Slow twist combined with pricking blood therapy by Qi stagnation and Blood stasis type of root ciatica in clinical research]. Unpublished data, 2012.(b)
  18. Zhai H. Clinical observation of sciatica treated by acupuncture. Medical Information. 2012;25(2):562. (a)
  19. Ren YX. [Clinical observation on 30 cases of lumber intervertebral disc herniation treated by warm needling combined with medicine]. Jiangsu Journal of Traditional Chinese Medicine. 2013;45(9):62–63.(b)
  20. Huang WD. Clinical observation of 76 cases of sciatica treated by acupuncture. Contemporary Medicine Forum. 2014;12(1):178–179.(a)
  21. Meng Rong. [Efficacy of electroacupuncture therapy and medication treatrnent on lumbar discherniation]. Journal Of Clinical Acupuncture And Moxibustion. 2014;30(9):30-32. gera[173485].(b)173485
  22. Wang CH. Clinical observation of sciatica treated by acupuncture. Asia-Pacific Traditional Médicine. 2014;10(6):94–95.(a)
  23. Qin Z, Liu X, Yao Q, Zhai Y, Liu Z; Acupuncture for treating sciatica: a systematic review protocol, BMJ Open; 2015;5(4).ID e007498, 2015. (a)
  24. Ye XC, Zhao P, Wang L et al. Clinical observation on the treatment of root scitica by electro acupuncture at Jiaji point. Information on Traditional Chinese Médicine. 2015;32(1):108–111.(a)