Treatment of Sciatica Pain
Start with NSAIDs as first-line medication for sciatica pain, combined with advice to remain active rather than bed rest, and consider adding gabapentin or tricyclic antidepressants for neuropathic pain components if NSAIDs alone are insufficient. 1, 2, 3
First-Line Pharmacologic Treatment
NSAIDs are the preferred initial medication for sciatic pain, offering superior pain relief compared to acetaminophen, though they carry gastrointestinal, renal, and cardiovascular risks that require assessment before prescribing. 1, 2, 3 Use the lowest effective dose for the shortest duration, particularly in older patients and those with cardiovascular, renal, or gastrointestinal risk factors. 1
Acetaminophen serves as an alternative when NSAIDs are contraindicated, with a more favorable safety profile and lower cost, though it provides slightly weaker analgesia. 2, 3 Monitor for asymptomatic aminotransferase elevations when using 4 g/day dosing. 3
For neuropathic pain components, add gabapentin, which provides small, short-term benefits specifically for radiculopathy. 4, 1, 3 Tricyclic antidepressants are effective for the neuropathic pain components of sciatica and should be considered in patients without contraindications. 4, 1, 3
Skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) provide short-term relief when muscle spasm contributes to pain, though they increase central nervous system adverse events. 4, 1, 3
First-Line Non-Pharmacologic Treatment
Advise patients to remain active rather than resting in bed, as this approach is more effective for managing radicular symptoms. 1, 2, 3 If bed rest is necessary for severe symptoms, encourage return to normal activities as soon as possible. 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 such as The Back Book to supplement clinical care and reduce disability. 1, 2
Second-Line Treatment Options
For acute sciatica (<4 weeks), spinal manipulation by appropriately trained providers shows small to moderate short-term benefits. 1, 2, 3
For chronic sciatica, implement individually tailored exercise programs that include supervision, stretching, and strengthening, which demonstrate small to moderate effects. 1, 2, 3 Consider adding massage therapy, which shows moderate effectiveness comparable to other proven interventions. 1, 2, 3
Cognitive-behavioral therapy provides moderate effects for chronic sciatic pain, with reductions of 10-20 points on a 100-point pain scale. 1, 2, 3
Acupuncture should be used as an adjunct to conventional therapy for chronic sciatic pain, as it is more effective than sham acupuncture. 1, 2, 3
Third-Line Interventional Options
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, 3
Sacroiliac joint injections provide symptomatic relief when sacroiliac joint dysfunction contributes to symptoms. 1, 2, 3
Spinal cord stimulation can be considered in multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. 1, 2, 3
Radiofrequency ablation of medial branch nerves may be considered for facet-related pain, and water-cooled radiofrequency ablation for chronic sacroiliac joint pain. 1, 2, 3
Surgical Considerations
Surgical consultation should be considered for patients with progressive neurological deficits or symptoms persisting beyond 6-8 weeks with confirmed disc herniation. 1, 2, 3 Discectomy is effective in the short term, but in the long term is not more effective than prolonged conservative care. 1
Immediate surgical intervention is required for cauda equina syndrome, which is a medical emergency. 1, 3
Critical Pitfalls to Avoid
Do not prescribe systemic corticosteroids, as they have not been shown to be more effective than placebo for sciatica. 4, 1, 3
Avoid prolonged bed rest, as it leads to deconditioning and potentially worsens symptoms. 1, 3
Do not order routine imaging for initial evaluation unless red flags are present (cauda equina syndrome, progressive neurological deficits, suspected infection, or malignancy). 1, 3
Reserve extended courses of medications for patients clearly showing continued benefits without major adverse events. 1, 3