What is the recommended treatment for sciatica?

Treatment of Sciatica

For acute sciatica, start with NSAIDs, staying active, and superficial heat—avoid bed rest and systemic corticosteroids entirely. 1, 2

Acute Phase Management (0-4 Weeks)

Activity Modification

• Advise patients to remain active rather than resting in bed, as staying active is significantly more effective than bed rest for managing radicular symptoms and prevents deconditioning. 1, 2, 3
• If severe symptoms temporarily require rest, return to normal activities within 1-2 days maximum. 3

First-Line Pharmacotherapy

• NSAIDs are the first-line medication, providing clinically meaningful pain reduction and disability improvement for acute sciatica. 1, 2
• Use the lowest effective NSAID dose for the shortest duration due to gastrointestinal bleeding, cardiovascular events, and renal toxicity risks. 1, 3
• Acetaminophen serves as an alternative in patients with NSAID contraindications (cardiovascular disease, chronic kidney disease, peptic ulcer disease), though it provides slightly weaker analgesia. 2, 3
• Add skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) for short-term relief when muscle spasm contributes to pain. 1, 3

Neuropathic Pain Adjuncts

• Gabapentin provides small, short-term benefits specifically for radiculopathy symptoms. 1, 3
• Tricyclic antidepressants offer pain relief for neuropathic components in patients without contraindications (cardiac conduction abnormalities, urinary retention, narrow-angle glaucoma). 3

Non-Pharmacologic Interventions

• Apply superficial heat using heating pads or heated blankets for short-term pain relief in the acute phase. 1, 2

Critical Avoidance

• Do not prescribe systemic corticosteroids—multiple trials demonstrate they are no more effective than placebo for acute sciatica. 1, 2, 3

Subacute Phase Management (4-8 Weeks)

Physical Interventions

• Spinal manipulation by appropriately trained providers (chiropractors, osteopaths, physical therapists) shows small to moderate short-term benefits for acute sciatica. 1, 2, 3
• Supervised exercise therapy becomes beneficial after 2-6 weeks, whereas it is ineffective in the first 4 weeks. 1
• Individually tailored exercise programs with supervision, stretching, and strengthening are effective for subacute symptoms, producing 10-point reductions on 100-point pain scales. 1, 3

Additional Modalities

• Massage therapy demonstrates moderate effectiveness for symptoms persisting beyond 4 weeks. 1, 2
• Acupuncture may provide benefit as an adjunct to conventional therapy for subacute sciatica. 1, 3
• Cognitive-behavioral therapy is effective for chronic symptoms, producing 10-20 point reductions on 100-point pain scales. 1, 3

Interventional Procedures

• Consider epidural steroid injections for patients with persistent radicular symptoms despite 4-6 weeks of conservative therapy. 2, 3

Chronic Phase Management (Beyond 8 Weeks)

Surgical Considerations

• Consider surgical consultation for patients with persistent symptoms beyond 6-8 weeks who have failed conservative management. 1, 2
• Discectomy is effective in the short term (6-12 weeks) but shows no superiority over prolonged conservative care at 1-2 years. 1, 2, 4
• The natural course of sciatica is generally favorable, with most pain and disability improving within 2-4 weeks with or without treatment. 5, 4

Advanced Interventions

• Spinal cord stimulation may be considered for persistent radicular pain unresponsive to other therapies. 1, 3
• Intensive interdisciplinary rehabilitation (combining physical, vocational, and behavioral components) is moderately more effective than non-interdisciplinary approaches for chronic sciatica. 3

Red Flags Requiring Immediate Action

• Cauda equina syndrome (urinary retention/incontinence, bilateral leg weakness, saddle anesthesia) requires immediate surgical intervention within 24-48 hours. 1, 3
• Rapidly progressive motor weakness requires urgent surgical consultation within 24-72 hours. 1, 3
• Suspected infection (fever, night sweats, immunosuppression) or malignancy (unexplained weight loss, age >50 with new onset, history of cancer) requires immediate imaging and specialist referral. 3, 5

Imaging Strategy

• Avoid routine imaging for acute sciatica without red flags, as it does not improve outcomes and may lead to unnecessary interventions. 2, 3
• Consider MRI (preferred over CT due to superior soft tissue visualization without radiation exposure) only after 4-6 weeks of persistent symptoms if the patient is a candidate for surgery or epidural injection. 1, 5
• Bulging discs on MRI without nerve root impingement are often nonspecific findings that correlate poorly with symptoms—always correlate imaging with clinical presentation. 1, 2

Critical Pitfalls to Avoid

• Never recommend prolonged bed rest beyond 1-2 days—it worsens outcomes through deconditioning and muscle atrophy. 1, 2, 3
• Do not prescribe systemic corticosteroids—they provide no benefit over placebo in multiple high-quality trials. 1, 2, 3
• Avoid extended medication courses (beyond 4-6 weeks) unless patients show clear continued benefits without adverse events. 1, 3
• Do not over-rely on imaging findings—disc herniations are present in 20-30% of asymptomatic individuals. 1
• Assess psychosocial factors (job satisfaction, depression, catastrophizing), which are stronger predictors of outcomes than physical findings. 1