What is the treatment for sciatica?

Treatment for Sciatica

The first-line treatment for sciatica should follow a risk-stratified approach using the STarT Back tool to categorize patients into low, medium, or high risk for persistent disabling pain, with management including non-pharmacologic therapies (exercise, physical therapy) and pharmacologic options (NSAIDs as first-line medication), reserving surgery for specific indications such as progressive neurological deficits or persistent symptoms despite 6-12 weeks of conservative management. 1

Risk Assessment and Management Approach

1. Initial Risk Stratification:

   • Use the STarT Back tool within 2 weeks of symptom onset 1
   • Categorize patients into:
     • Low risk → Self-management with appropriate pain relief and education
     • Medium risk → Physiotherapy with patient-centered management plan
     • High risk → Comprehensive biopsychosocial assessment and physiotherapy

2. Document Red Flags requiring urgent evaluation:

   • Age >50 or <20 years
   • History of cancer, unexplained weight loss
   • Fever, chills, recent infection
   • Saddle anesthesia, bladder/bowel dysfunction
   • Progressive neurological deficits 1

Conservative Treatment

Non-Pharmacologic Options (First-Line)

• Exercise therapy
• Multidisciplinary rehabilitation
• Acupuncture
• Mindfulness-based stress reduction
• Tai chi, yoga
• Motor control exercise
• Cognitive behavioral therapy
• Spinal manipulation 1

Pharmacologic Treatment

• First-line: NSAIDs (moderate-quality evidence) 1
• Alternatives:
  • Skeletal muscle relaxants (moderate-quality evidence)
  • Acetaminophen for those who cannot take NSAIDs
  • Neuropathic pain medications (gabapentin, pregabalin) if radicular component is prominent 1
• Second-line: Tramadol or duloxetine 1
• Last resort: Opioids only after failure of other treatments and only if benefits outweigh risks 1

The older recommendation of complete bed rest for 2 weeks 2 is now considered outdated, as current guidelines emphasize maintaining activity as tolerated.

Diagnostic Considerations

• Imaging is not recommended for nonspecific low back pain
• Consider imaging only for:
  • Severe or progressive neurological deficits
  • Suspected serious underlying conditions
  • Persistent symptoms with radiculopathy if surgery or epidural injection is being considered 1
• MRI is preferred over CT as it better visualizes soft tissues and avoids radiation exposure 3

Surgical Intervention

Surgery should be considered only in specific circumstances:

• Cauda equina syndrome (emergency)
• Progressive neurological deficits
• Motor deficit greater than grade 3
• Persistent radicular symptoms despite 6-12 weeks of conservative treatment
• Intractable pain despite comprehensive conservative management 1

Lumbar discectomy is the established procedure for primary disc herniation with radiculopathy when conservative management fails. Importantly, lumbar fusion is NOT recommended as a routine treatment following primary disc excision 1.

Special Populations

• Elderly patients: Slower progression of exercise intensity and careful medication management due to higher risk of medication side effects 1
• Cardiovascular disease or renal impairment: Special attention with NSAID use 1
• Patients with Ehlers-Danlos Syndrome: May benefit from multidisciplinary approach involving rheumatology, cardiology, or nephrology 1

Follow-Up Protocol

• Close follow-up within 48-72 hours to reassess symptoms
• Document specific timeframe for follow-up and criteria for earlier reassessment
• If symptoms persist beyond 6 weeks despite appropriate management, consider additional imaging or specialist referral 1

Clinical Course and Prognosis

The natural history of sciatica is generally favorable, with most pain and related disability improving within 2-4 weeks with or without treatment 3. This positive prognosis should be communicated to patients to provide reassurance.

Common Pitfalls to Avoid

• Rushing to imaging before adequate conservative management trial (6-8 weeks)
• Overreliance on opioid medications
• Neglecting psychosocial factors, which are stronger predictors of outcomes than physical examination findings or pain severity
• Recommending routine fusion following primary disc excision
• Failing to recognize true sciatica (radicular pain) versus referred pain from the lower back 4