What is the initial workup and management for a patient presenting with sciatica?

Workup and Management of Sciatica

The initial workup for sciatica should include a focused history and physical examination to identify the cause, with imaging reserved for cases with red flags or symptoms that don't improve after 6-8 weeks of conservative treatment. 1

Initial Assessment

History

• Pain characteristics:
  • Radiation pattern below the knee into foot and toes (distinguishes true radiculopathy from referred pain)
  • Severity, duration, and exacerbating/relieving factors
  • Impact on daily activities and quality of life
• Associated symptoms:
  • Sensory changes (numbness, tingling)
  • Motor weakness
  • Bowel/bladder dysfunction (red flag for cauda equina syndrome)

Physical Examination

• Neurological examination:
  • Motor strength testing of lower extremities
  • Sensory testing in dermatomes
  • Deep tendon reflexes
• Provocative tests:
  • Straight-leg-raise test (30-70° reproduction of sciatic pain) 2
  • Crossed straight-leg-raise test (positive when unaffected leg raises cause sciatic pain) 2
  • FABER test (Flexion, ABduction, External Rotation)
  • Piriformis testing (Flexion, ADduction, and Internal Rotation of hip) 3

Red Flags Requiring Urgent Evaluation

• Cauda equina syndrome (urinary retention/incontinence, bilateral weakness, saddle anesthesia) 2
• Significant or progressive neurological deficit
• Suspected infection or malignancy
• Recent trauma
• Severe, unrelenting pain unresponsive to conservative measures

Diagnostic Testing

• Imaging is NOT routinely indicated for acute sciatica 4

• Consider imaging when:

  • Red flags are present
  • Symptoms persist beyond 6-8 weeks despite conservative treatment 1
  • Severe symptoms or progressive neurological deficits exist

• MRI is the preferred imaging modality for suspected disc herniation 1

  • Better visualization of soft tissues than CT
  • No ionizing radiation exposure
  • Can identify nerve root compression, disc herniation, and other pathologies

Initial Management (First 6-8 Weeks)

First-Line Treatments

1. Patient education and reassurance:

   • Favorable natural history (most improve within 2-4 weeks) 1
   • Advise to stay active rather than bed rest 4

2. Non-pharmacological approaches:

   • Physical therapy with core stability exercises 4
   • Stretching exercises (knee-to-chest, piriformis, hip flexor) 4
   • Strengthening exercises (glute bridges, wall squats) 4
   • Neurodynamic exercises may improve outcomes 5

3. Pharmacological management:

   • NSAIDs (first-line if no contraindications) 4
     • Ibuprofen 400-600mg every 6 hours (max 2400mg daily)
     • Naproxen 250-500mg twice daily (max 1000mg daily)
     • Consider gastroprotection in high-risk patients
   • Acetaminophen 500-1000mg every 6 hours (max 4000mg daily) 4
   • Muscle relaxants for acute spasm

Second-Line Treatments

• Adjunctive medications for neuropathic pain:

  • Gabapentin (starting at 300mg daily, titrating up to 900mg TID) 6
  • Pregabalin
  • Duloxetine (SNRI)

• Short-course oral corticosteroids may be considered as a bridging option 4

Management for Persistent Symptoms (Beyond 6-8 Weeks)

• Reassessment and imaging (MRI preferred) 1

• Consider epidural steroid injections for temporary relief

• For piriformis syndrome (non-discogenic sciatica), consider:

  • Targeted physical therapy
  • Piriformis injections (corticosteroid or botulinum toxin) 3

• Surgical consultation for:

  • Persistent disabling symptoms despite conservative treatment
  • Progressive neurological deficits
  • Cauda equina syndrome (emergency)

Follow-Up Recommendations

• Reassess at 2-4 weeks to evaluate response to initial treatment 4
• Use STarT Back tool at 2 weeks to predict risk of developing persistent disabling pain 4
• Consider psychosocial factors that may contribute to pain chronicity 4
• If symptoms persist beyond 6-8 weeks, consider imaging and specialist referral

Common Pitfalls to Avoid

1. Ordering unnecessary imaging for acute sciatica without red flags
2. Prolonged bed rest (worsens outcomes)
3. Prolonged use of opioids (limited evidence for efficacy in sciatica)
4. Failing to distinguish radicular pain from referred back pain
5. Missing serious underlying pathologies by not recognizing red flags
6. Overlooking non-discogenic causes of sciatica (e.g., piriformis syndrome) 3