What are the recommended treatments for sciatica?

Sciatica Treatment

For sciatica, advise patients to remain active rather than bed rest, start NSAIDs as first-line medication, apply heat for acute pain relief, and consider epidural steroid injections or surgery only after 6-8 weeks of failed conservative management. 1, 2, 3

Initial Management Approach

Activity and Self-Care

• Patients should remain active and avoid prolonged bed rest, as staying active is more effective than bed rest for managing radicular symptoms and prevents deconditioning 1, 2, 3
• Apply superficial heat using heating pads or heated blankets for short-term relief of acute sciatic pain 1, 2, 3
• Provide evidence-based self-care education materials to supplement clinical advice 2

First-Line Pharmacological Treatment

• NSAIDs are the preferred first-line medication for sciatic pain, offering superior pain relief compared to acetaminophen (approximately 10 points better on a 100-point visual analogue scale) 4, 1, 2, 3
• Acetaminophen is a reasonable alternative with a more favorable safety profile and lower cost, particularly for patients with gastrointestinal, renal, or cardiovascular risk factors 4, 1, 3
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and use the lowest effective dose for the shortest duration necessary 4, 1
• Consider skeletal muscle relaxants for short-term relief when muscle spasm contributes to pain 1

Neuropathic Pain Components

• Gabapentin shows small, short-term benefits for patients with radiculopathy 1
• Tricyclic antidepressants may be effective for neuropathic pain components of sciatica 1
• Since sciatica often involves mixed pain mechanisms (nociceptive and neuropathic), combining these agents with NSAIDs may be useful in patients not responding to NSAIDs alone 5

Second-Line Treatment (After Initial Conservative Management)

Physical Interventions

• Individually tailored exercise programs with supervision, stretching, and strengthening are effective for chronic sciatic pain 1, 2, 3
• Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute sciatica 1, 2, 3
• Massage therapy provides moderate effectiveness for chronic sciatica 1, 2, 3
• Acupuncture may be beneficial as an adjunct therapy for chronic sciatic pain 1, 2

Psychological Interventions

• Cognitive-behavioral therapy is effective for chronic pain management 1, 2
• Intensive interdisciplinary rehabilitation combining physical, vocational, and behavioral components is effective for chronic sciatica 2

Third-Line Treatment (For Persistent Symptoms After 6-8 Weeks)

Interventional Procedures

• Epidural steroid injections should be considered for patients with persistent radicular symptoms despite conservative therapy 1, 2, 3
• Medial branch blocks may be used for facet-mediated spine pain contributing to sciatica 1, 2
• Sacroiliac joint injections provide symptomatic relief when sacroiliac joint dysfunction contributes to symptoms 1, 2
• Botulinum toxin may be used as an adjunct for piriformis syndrome when it contributes to sciatic symptoms 1, 2, 6
• Radiofrequency ablation of medial branch nerves or water-cooled radiofrequency ablation for chronic sacroiliac joint pain 1, 2
• Spinal cord stimulation can be considered in multimodal treatment of persistent radicular pain in patients who have not responded to other therapies 1, 2

Surgical Management

• Surgical consultation should be considered for patients with progressive neurological deficits or symptoms persisting beyond 6-8 weeks with confirmed disc herniation 2, 3
• Discectomy is effective in the short term, but in the long term it is not more effective than prolonged conservative care 1, 3, 7
• Immediate surgical intervention is required for cauda equina syndrome, which is a medical emergency 1

Critical Pitfalls to Avoid

• Do not recommend prolonged bed rest as it leads to deconditioning and potentially worsens symptoms 1, 3
• Systemic corticosteroids are not recommended as they have not been shown to be more effective than placebo 1, 3
• Routine imaging is not recommended for initial evaluation unless red flags are present (cauda equina syndrome, progressive neurological deficits, suspected infection, or malignancy) 1, 3
• Extended courses of medications should be reserved for patients clearly showing continued benefits without major adverse events 1, 3
• MRI findings such as bulging discs may be nonspecific and should be correlated with clinical symptoms 3

Timeline for Treatment Escalation

• First 6-8 weeks: Conservative management only (activity, NSAIDs, heat, physical therapy) 7, 8
• After 6-8 weeks: Consider imaging (MRI preferred) and interventional procedures if symptoms persist 8
• After 3 months: Consider surgical consultation if conservative and interventional treatments have failed 9