From the Guidelines
Treatment of sciatica should prioritize a combination of self-care measures, medications, and physical therapy, with a focus on reducing inflammation and pressure on the sciatic nerve. For acute sciatica, patients should start with rest for 1-2 days, followed by gentle activity as tolerated. Over-the-counter pain relievers like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) can reduce inflammation and pain, as suggested by the American College of Physicians and the American Pain Society 1. Apply ice packs for 20 minutes several times daily during the first 48-72 hours, then switch to heat therapy. Prescription medications may include muscle relaxants like cyclobenzaprine (5-10mg three times daily) for muscle spasms, or in severe cases, short-term oral corticosteroids like prednisone (tapering dose starting at 60mg daily). However, systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1.
Key Considerations
- Physical therapy focusing on core strengthening and stretching exercises should begin once acute pain subsides, as it has proven benefits for chronic or subacute low back pain 1.
- Maintain proper posture and ergonomics during daily activities, and consider using a lumbar support pillow when sitting.
- For persistent sciatica lasting more than 6-12 weeks, epidural steroid injections may provide temporary relief.
- Surgery is typically reserved for cases with significant nerve compression or when conservative treatments fail after 6-12 months.
- Gabapentin is associated with small, short-term benefits in patients with radiculopathy, but its use should be weighed against potential risks and benefits 1.
Medication Management
- Over-the-counter pain relievers and prescription medications should be used judiciously, with consideration of potential side effects and interactions.
- Benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief, but are also associated with risks for abuse, addiction, and tolerance 1.
- Herbal therapies, such as devil's claw, willow bark, and capsicum, seem to be safe options for acute exacerbations of chronic low back pain, but benefits range from small to moderate 1.
From the Research
Treatment Options for Sciatica
- The treatment for sciatica (lumbar radiculopathy) can be conservative or surgical, with the choice of treatment depending on the severity and duration of symptoms 2, 3, 4, 5.
- Conservative treatment options include:
- Bed rest and anti-inflammatory drugs, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) 5.
- Physiotherapy interventions, such as exercise therapy and symptom-guided exercises 3, 6.
- Epidural steroid injections, which may be beneficial for subgroups of patients with nerve root compression 2, 4.
- Surgical treatment options include microdiscectomy, which may be considered for patients with severe or persistent symptoms who have not responded to conservative treatment 4.
Effectiveness of Treatment Options
- The effectiveness of conservative treatment options for sciatica is variable, with some studies showing significant improvements in symptoms and function, while others show little or no benefit 2, 3, 6.
- A systematic review and meta-analysis of physiotherapy interventions for sciatica found no significant difference in pain or disability between physiotherapy and control interventions, although subgroup analysis suggested that physiotherapy may be beneficial for patients with minimal intervention 6.
- A randomized controlled trial comparing microdiscectomy with transforaminal epidural steroid injection for sciatica found no significant difference in outcomes between the two treatments, although microdiscectomy was associated with a higher risk of adverse events 4.
Recommendations for Treatment
- The choice of treatment for sciatica should be individualized based on the severity and duration of symptoms, as well as the patient's preferences and medical history 2, 3, 4, 5.
- Conservative treatment options should be tried first, with surgical treatment considered for patients with severe or persistent symptoms who have not responded to conservative treatment 4, 5.
- Further research is needed to determine the most effective treatment options for sciatica and to reduce clinical heterogeneity and uncertainty surrounding treatment outcomes 2, 3, 4, 6.