From the Guidelines
Sciatica treatment should prioritize non-pharmacologic therapies with proven benefits, such as spinal manipulation for acute low back pain and intensive interdisciplinary rehabilitation for chronic or subacute low back pain. The causes of sciatica are multifactorial, often resulting from compression or irritation of the sciatic nerve due to a herniated disc, bone spur, spinal stenosis, or piriformis syndrome 1.
Initial Management
Treatment begins with conservative approaches, including:
- Rest for 1-2 days
- Gentle stretching and strengthening exercises targeting the lower back and legs
- Over-the-counter pain medications like ibuprofen or naproxen to reduce inflammation and pain
- Application of ice packs for 20 minutes several times daily during the first 48-72 hours, then switching to heat therapy using heating pads or warm baths for 20 minutes at a time
Pharmacologic Interventions
For patients who do not improve with self-care options, pharmacologic interventions may be considered, such as:
- Gabapentin, which is associated with small, short-term benefits in patients with radiculopathy 1
- Muscle relaxants, like cyclobenzaprine, for short-term pain relief
- 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
Alternative Therapies
Herbal therapies, such as devil's claw, willow bark, and capsicum, may be safe options for acute exacerbations of chronic low back pain, but their benefits range from small to moderate 1.
Advanced Interventions
For persistent pain, advanced interventions like epidural steroid injections or surgery may be necessary, typically reserved for cases with significant nerve damage, progressive weakness, or when conservative treatments fail after 6-12 weeks. Most medication trials evaluated patients with nonspecific low back pain or mixed populations with and without sciatica, highlighting the need for personalized treatment approaches 1.
From the Research
Causes of Sciatica
- Sciatica is often caused by disc herniations 2
- Neuropathic pain mechanisms can also contribute to sciatica 3
Conservative Treatments for Sciatica
- The natural course of sciatica seems to be favorable, and many patients are managed conservatively at first 2
- Combined conservative interventions, such as exercise and advice to stay active, may be effective in reducing pain and disability in people with sciatica 3, 4
- Epidural steroids may be beneficial for subgroups of nerve root compression 2
- There is low-quality evidence that exercise provides small, superior effects compared with advice to stay active on leg pain in the short term for patients experiencing sciatica 4
Pharmacological Treatments for Sciatica
- The evidence to judge the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and opioid analgesics for sciatica is of moderate to low quality 5
- Corticosteroids and the anticonvulsant gabapentin may show some benefits in the short term, but the evidence is limited 5