From the Guidelines
For a resident with increasing sciatica pain in the left leg, I strongly recommend starting with a supervised exercise program, such as back school or brief individualized educational interventions, to address the underlying causes of the pain and improve quality of life. This approach is supported by the American College of Physicians and the American Pain Society, which suggest that exercise and education are key components of managing low back pain and sciatica 1.
When it comes to diagnosing the cause of sciatica, the straight-leg-raise test can be a useful tool to assess nerve root tension 1. A positive test, which reproduces the patient's sciatica when the leg is raised between 30 and 70 degrees, can indicate compression or irritation of the sciatic nerve.
In terms of treatment, a multi-faceted approach that combines medication, physical therapy, and lifestyle modifications is often most effective. Over-the-counter pain relievers like ibuprofen or naproxen can help with anti-inflammatory effects, while gentle stretching exercises focusing on the piriformis muscle, hamstrings, and lower back can provide relief. Physical therapy, including interventions like functional restoration or interdisciplinary rehabilitation, can help improve strength, endurance, and flexibility, reducing the risk of long-term disability and improving quality of life 1.
It's also important to consider alternative therapies, such as acupuncture or acupressure, which may provide additional pain relief for some patients 1. However, the evidence for these therapies is not as strong as for exercise and education, and they should be used in conjunction with, rather than in place of, more established treatments.
Ultimately, the goal of treatment should be to reduce pain, improve function, and enhance quality of life, while also addressing the underlying causes of the sciatica and preventing long-term complications 1.
From the Research
Management of Sciatica Pain
- The management of sciatica pain, including the use of analgesic and adjuvant pain drugs, has been investigated in several studies 2, 3.
- A systematic review and meta-analysis published in 2012 found that the evidence for the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and opioid analgesics in managing sciatica ranged from moderate to low quality 2.
- The review found that most of the pooled estimates did not favor the active treatment over placebo, except for corticosteroids and the anticonvulsant gabapentin, which showed some benefits in the short term 2.
Combination Drug Therapy
- A systematic review and meta-analysis published in 2019 investigated the effects of combination drug therapy in patients with low back pain and/or sciatica on pain, disability, and adverse events 3.
- The review found that most combinations had no or small effect on pain and disability, and there was no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence 3.
- However, one combination, buprenorphine plus pregabalin, was found to have a clinically important difference in pain relief compared to buprenorphine alone, although the quality of evidence was low 3.
Adverse Events
- The studies found that the median rate of adverse events was 17% for active drugs and 11% for placebo 2.
- The 2019 review found that there was no statistically significant increased risk of serious adverse events with combination drug therapy, and when the risk of adverse events was statistically significant, it favored monotherapy or placebo 3.