What is the preferred treatment for lumbago with sciatica, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) or steroids?

NSAIDs are Preferred Over Steroids for Lumbago with Sciatica

NSAIDs are recommended as first-line drug treatment for lumbago with sciatica, while systemic corticosteroids are not recommended due to lack of evidence for long-term benefit. 1, 2

Evidence for NSAIDs in Lumbago with Sciatica

• NSAIDs are recommended as first-line pharmacological treatment for patients with low back pain and sciatica, with convincing evidence that they improve spinal pain, peripheral joint pain, and function over short time periods 1
• For back pain with sciatica specifically, NSAIDs provide moderate efficacy for pain relief, though evidence suggests they may be slightly less effective for sciatica than for non-radicular low back pain 1, 3
• Continuous NSAID treatment is conditionally recommended over on-demand treatment for patients with persistently active, symptomatic disease 1
• No particular NSAID has been shown to be more effective than others for treating low back pain with sciatica; choice should be based on the patient's risk profile and comorbidities 1

Evidence Against Systemic Corticosteroids

• Systemic corticosteroids are not recommended for low back pain with or without sciatica, as they have not demonstrated superiority over placebo 2, 4
• A Cochrane review found no support for any type of systemic administration of corticosteroids for low back pain or sciatica 4
• While local epidural steroid injections may provide short-term benefit for sciatica, they show no additional improvement over placebo in the long-term management 5, 4

Treatment Algorithm for Lumbago with Sciatica

1. First-line treatment: NSAIDs

   • Start with standard doses of NSAIDs (e.g., ibuprofen, naproxen, or meloxicam) 1, 6
   • Consider cardiovascular, gastrointestinal, and renal risks when prescribing NSAIDs 1, 7
   • For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1

2. Adjunctive treatments to consider:

   • Muscle relaxants can be added for short-term use when muscle spasm contributes to pain 2, 6
   • Combining NSAIDs with muscle relaxants may provide enhanced pain relief but increases the risk of central nervous system adverse events 2
   • For the neuropathic component of sciatica, gabapentin may be considered as it has shown small to moderate short-term benefits 2, 6

3. If NSAIDs are insufficient or contraindicated:

   • Analgesics such as acetaminophen and opioids might be considered for pain control 1
   • Tricyclic antidepressants (e.g., amitriptyline) have shown moderate efficacy for chronic low back pain 2

4. Non-pharmacological approaches:

   • Include patient education and regular exercise throughout treatment 1
   • Individual and group physical therapy should be considered 1

Important Considerations and Pitfalls

• NSAIDs carry risks of gastrointestinal bleeding, which is dose-dependent and can be reduced with gastroprotective agents 1, 7
• Cardiovascular risks should be considered when prescribing NSAIDs, especially for long-term use 1, 7
• Local corticosteroid injections may be considered for isolated active sacroiliitis, enthesitis, or peripheral arthritis that doesn't respond to NSAIDs 1
• The evidence for efficacy of NSAIDs specifically for sciatica is less robust than for non-radicular low back pain, with some studies showing comparable pain reduction between NSAIDs and placebo 3
• For most patients with acute low back pain, NSAIDs provide only a small benefit over placebo that may not be clinically significant 8

Special Populations

• In elderly patients or those with comorbidities, the risk-benefit ratio of NSAIDs should be carefully considered due to increased risk of adverse effects 7
• For patients with contraindications to NSAIDs, acetaminophen may be considered as an alternative, though it provides slightly less pain relief 6