Author’s reply to Bernard and GraysonBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2562 (Published 10 April 2012) Cite this as: BMJ 2012;344:e2562
- Roger Chou, associate professor of medicine1
- 1Department of Medicine and Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97225, USA
Bernard and Grayson both suggest that an editorial on drugs for sciatica/radiculopathy should have addressed surgery and epidural steroid injections.1 2 However, both my editorial and the systematic review it commented on focused on the benefits and harms of systemic drugs.3 4 Other types of treatment for sciatica, including surgery and epidural steroids, have been reviewed elsewhere.5 6 Indeed, most trials of epidural steroids for radiculopathy show some short term benefit compared with a sham procedure, but no long term benefits.5 Some trials of surgery also find that short term benefits compared with non-surgical therapy were no longer present long term.6
As Bernard points out,1 L4/L5 and L5/S1 refer to disc levels. The nerve roots affected by disc herniations at these levels vary depending on the location of the herniation, although the corresponding nerve roots usually affected are L5 and S1. Pain and motor deficits associated with L5 and S1 radiculopathy are usually in typical dermatomal and myotomal distributions, although overlap and variation can occur.7
I did not state that radiculopathy is primarily caused by far lateral extraforaminal protrusions. In fact, compression can occur anywhere along the nerve root after it emerges from the spinal cord. In any case, the specific location of nerve root compression and the dermatomal distribution of symptoms have no bearing on drug effectiveness or drug choices for this condition.
Cite this as: BMJ 2012;344:e2562
Competing interests: RC has received research funding from the American Pain Society to develop guidelines on low back pain evaluation and treatment; he is a consultant for Wellpoint, Blue Cross Blue Shield Association, and Palladian Health (all of which deliver or manage healthcare and do not manufacture drugs).