What is the treatment for sciatica?

Treatment of Sciatica

The first-line treatment for sciatica should include NSAIDs for pain control, continued activity as tolerated, and heat therapy for 1-2 weeks, followed by physical therapy with active exercises if symptoms persist. 1

Initial Management (0-2 weeks)

• Pharmacological options:

  • NSAIDs for up to one week (provides small to moderate pain improvement compared to placebo) 1
  • Consider adding muscle relaxants (cyclobenzaprine) for muscle spasm for short periods (up to 2-3 weeks) 1, 2
  • Acetaminophen may be used for pain control 1

• Non-pharmacological options:

  • Heat therapy (moderately improves pain relief and disability) 1
  • Encourage continued activity as tolerated rather than strict bed rest 1, 3
  • Patient education about the generally favorable clinical course (most improve within 2-4 weeks with or without treatment) 3

If Inadequate Response After 1-2 Weeks

• Refer to physical therapy with focus on active exercises rather than passive interventions 1
• For persistent pain with neuropathic features, consider:
  • Gabapentin or pregabalin for neuropathic component 1, 4
  • Duloxetine (30-60mg daily) shows moderate evidence for small improvements in pain intensity 1

Important Clinical Considerations

• Sciatica is a symptom characterized by lower limb pain radiating below the knee into the foot and toes, typically caused by herniated lumbar disc 3, 5
• Use sciatic tension tests (straight leg raise) to confirm the presence of sciatica 6
• The STarT Back tool can help categorize patients into low, medium, or high risk for developing persistent disabling pain, guiding management plans 1

When to Consider Surgery

• Surgery should be considered only in specific circumstances:

  • Cauda equina syndrome (emergency)
  • Progressive neurological deficits
  • Significant motor deficits
  • Persistent radicular symptoms despite 6-12 weeks of conservative treatment 1, 3

• MRI is the preferred imaging modality but is warranted only if:

  • Evidence suggests pathology other than disc herniation (infection, malignancy)
  • Severe symptoms don't improve after 6-8 weeks of conservative treatment 3

Avoiding Common Pitfalls

• Systemic corticosteroids have limited evidence for non-radicular back pain and should not be first-line therapy 1
• Limit NSAID use to one week when possible to avoid gastrointestinal, renal, and cardiovascular adverse effects 1
• Opioids should only be prescribed as a last resort and for very limited duration 1
• Avoid premature imaging, which can lead to unnecessary surgical interventions 1
• Older recommendations for complete bed rest (2 weeks) are outdated; current evidence supports continued activity as tolerated 1, 7
• Cyclobenzaprine should only be used for short periods (up to 2-3 weeks) as there is no evidence for effectiveness with prolonged use 2