What is the recommended treatment for new onset sciatica?

Treatment Recommendations for New Onset Sciatica

For new onset sciatica, first-line treatment should include self-care options such as staying active, applying heat, and using over-the-counter NSAIDs, with consideration of spinal manipulation for those who don't improve with self-care. 1

Initial Management Approach

• Begin with patient education about the generally favorable natural course of sciatica, with most patients experiencing significant improvement within 2-4 weeks with or without treatment 2
• Recommend staying active within pain limits rather than strict bed rest, as prolonged inactivity can worsen outcomes 1
• Apply superficial heat using heating pads or heated blankets for short-term relief of acute symptoms 1
• Start NSAIDs at maximum tolerated and approved dosage as first-line medication treatment 1
• Acetaminophen is a reasonable alternative for patients who cannot tolerate NSAIDs, though it provides slightly less pain relief 1

Medication Options

• NSAIDs provide more effective pain relief than acetaminophen but carry gastrointestinal and cardiovascular risks that should be considered 1
• Short courses of oral prednisolone or muscle relaxants may be considered as bridging options for severe pain 1
• Avoid long-term use of glucocorticoids due to potential adverse effects 1
• Gabapentin may be considered for patients with radiculopathy (nerve root pain), as it has shown small, short-term benefits 1
• Opioids should be reserved only for severe, disabling pain that is not controlled with other medications, and only for short-term use due to substantial risks 1

Non-Pharmacological Interventions

• Spinal manipulation administered by providers with appropriate training shows small to moderate short-term benefits for acute low back pain with sciatica 1
• Physical therapy may be beneficial, though supervised exercise therapy is not proven effective for acute sciatica 1
• Heat wrap therapy has shown moderate superiority to placebo and even to oral acetaminophen or ibuprofen for short-term pain relief 1
• Avoid transcutaneous electrical nerve stimulation (TENS) and traction, as they have not been proven effective for sciatica 1

When to Consider Advanced Treatment

• If symptoms do not improve after 6-8 weeks of conservative treatment, imaging (preferably MRI) may be warranted 2
• Consider consultation with a specialist if there is no improvement after standard noninvasive therapies 1
• Watch for red flags requiring immediate attention: cauda equina syndrome (urinary retention/incontinence, bilateral motor weakness, saddle anesthesia) or progressive neurological deficits 1

Common Pitfalls to Avoid

• Prescribing bed rest for more than a few days, as this can lead to deconditioning and prolonged disability 1
• Starting opioids as first-line treatment, which can lead to dependence and worse long-term outcomes 1
• Ordering imaging studies too early (before 6-8 weeks) in the absence of red flags, as this can lead to unnecessary interventions 2
• Failing to differentiate true radicular pain (sciatica) from referred pain from the lower back, which requires different treatment approaches 3

By following this evidence-based approach, most patients with new onset sciatica will experience significant improvement within several weeks. The treatment algorithm emphasizes conservative management first, with a stepwise progression to more advanced interventions only if necessary.