From the Guidelines
The best way to treat sciatica is through a combination of self-care measures, nonpharmacologic therapy, and medication, with a focus on reducing inflammation and pressure on the sciatic nerve. When treating sciatica, it is essential to prioritize self-care measures, such as rest, gentle stretching, and strengthening exercises targeting the lower back and legs, as well as maintaining good posture and using proper body mechanics when lifting 1. For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits, such as spinal manipulation for acute low back pain, or intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation for chronic or subacute low back pain 1. Medications such as gabapentin, which is associated with small, short-term benefits in patients with radiculopathy, may also be considered, although there is insufficient evidence to recommend for or against other antiepileptic drugs for back pain with or without radiculopathy 1. Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1. It is crucial to note that most medication trials evaluated patients with nonspecific low back pain or mixed populations with and without sciatica, and there is little evidence to guide specific recommendations for medications for patients with sciatica or spinal stenosis 1. Therefore, extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events. In terms of specific medications, tricyclic antidepressants may be an option for pain relief in patients with chronic low back pain and no contraindications to this class of medications, while herbal therapies such as devil's claw, willow bark, and capsicum may be safe options for acute exacerbations of chronic low back pain, although benefits range from small to moderate 1. Ultimately, the goal of treatment should be to reduce inflammation and pressure on the sciatic nerve, and to improve the patient's quality of life, while minimizing the risk of adverse events and promoting optimal morbidity and mortality outcomes.
From the Research
Treatment Options for Sciatica
- Conservative treatment is often the first approach for managing sciatica, with the natural course of the condition seeming to be favorable 2
- Epidural steroids may be beneficial for subgroups of nerve root compression, with possible effectiveness for sciatica 2
- Combined conservative interventions, such as exercise therapy and non-pharmacological interventions, may be more effective than single interventions for reducing back pain and disability in people with sciatica 3
Pharmaceutical and Interventional Treatments
- Subcutaneous anti-tumor necrosis factor-α (anti-TNF-α) was found to be superior to epidural steroid + anesthetic in reducing lumbar pain in both acute and chronic sciatica patients 4
- Epidural steroid demonstrated a better ability regarding the Oswestry disability score (ODI) compared to subcutaneous anti-TNF-α 4
- Intravenous anti-TNF-α ranked first in leg pain relief, while subcutaneous anti-TNF-α ranked first in lumbar pain relief, and epidural steroid ranked first in ODI 4
Surgical Interventions
- Microdiskectomy was found to be superior to non-surgical care in reducing leg pain intensity at 6 months of follow-up in patients with sciatica lasting more than 4 months and caused by lumbar disk herniation 5
- Surgery may be considered for patients with persistent sciatica, with microdiskectomy being a viable option 5