What is the treatment for sciatica?

Treatment of Sciatica

Start with NSAIDs and staying active as first-line treatment for sciatica, avoiding bed rest beyond brief periods for severe symptoms. 1, 2, 3

First-Line Treatment Approach

Non-Pharmacological Management

• Advise patients to remain active rather than resting in bed, as activity is more effective than bed rest for managing radicular symptoms 1, 2, 3
• If severe symptoms require bed rest, limit it to the shortest duration possible and encourage return to normal activities as soon as tolerable 1
• Apply superficial heat using heating pads or heated blankets for short-term pain relief in acute sciatica 1, 3
• Provide evidence-based self-care education materials (such as The Back Book) to supplement clinical care 1, 3

Pharmacological Management

• NSAIDs are the preferred first-line medication for sciatic pain, offering superior pain relief compared to acetaminophen 2, 3
• NSAIDs carry gastrointestinal, renal, and cardiovascular risks, so assess risk factors before prescribing and use the lowest effective dose for the shortest duration 1
• Acetaminophen is an acceptable alternative for patients with contraindications to NSAIDs, though it provides slightly weaker analgesia 1, 3
• Consider skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) for short-term relief when muscle spasm contributes to pain 4, 1
• Gabapentin provides small, short-term benefits for patients with radiculopathy, though evidence is limited to small trials 4, 1
• Tricyclic antidepressants offer pain relief for patients with neuropathic pain components of sciatica without contraindications 1, 5

Critical pitfall to avoid: Systemic corticosteroids are NOT recommended—they have not been shown to be more effective than placebo for sciatica 4, 1, 2

Second-Line Treatment for Persistent Symptoms (Beyond 4-6 Weeks)

Non-Pharmacological Therapies

• Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute sciatica (<4 weeks) 1, 2, 3
• Exercise therapy with individual tailoring, supervision, stretching, and strengthening is effective for chronic sciatic pain 1, 2, 3
• Acupuncture as an adjunct to conventional therapy for chronic sciatica 1, 3
• Massage therapy demonstrates moderate effectiveness for chronic low back pain with sciatica 1, 2, 3
• Cognitive-behavioral therapy for chronic pain management 1, 3
• Intensive interdisciplinary rehabilitation combining physical, vocational, and behavioral components is moderately more effective than non-interdisciplinary approaches for chronic sciatica 1, 3

When to Consider Imaging

• Do NOT obtain routine imaging for acute sciatica without red flags, as it doesn't improve outcomes and may lead to unnecessary interventions 1, 2
• Red flags requiring immediate evaluation include: cauda equina syndrome (bowel/bladder dysfunction), progressive neurological deficits, suspected infection, or malignancy 1, 2
• Consider MRI or CT only for persistent symptoms beyond 6-8 weeks if the patient is a potential candidate for surgery or epidural steroid injection 1, 6
• MRI is the preferred imaging modality when warranted, providing superior soft-tissue contrast without ionizing radiation 2, 3, 6

Third-Line Treatment for Refractory Cases

Interventional Procedures

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

Surgical Consultation

• Consider surgical consultation for patients with progressive neurological deficits or symptoms persisting beyond 6-8 weeks with confirmed disc herniation 1, 2, 3
• Immediate surgical intervention is required for cauda equina syndrome, which is a medical emergency 1
• Evidence shows discectomy is effective in the short term, but long-term outcomes are not superior to prolonged conservative care 2, 7

Important Clinical Considerations

Medication Duration and Monitoring

• Extended courses of medications should be reserved for patients clearly showing continued benefits without major adverse events 1, 2
• Monitor for asymptomatic aminotransferase elevations with acetaminophen at 4 g/day dosing 1

Opioid Use Caution

• Opioids are NOT recommended as first-line therapy for sciatica 4
• If opioids are prescribed for severe, disabling pain not controlled by NSAIDs or acetaminophen, use the lowest practical dose for limited duration (e.g., 1 week) 4
• Evidence for opioid superiority over NSAIDs or muscle relaxants for acute low back pain is lacking 4
• Workers treated with opioids within 6 weeks of acute injury for more than 7 days have significantly higher risk for long-term disability 4

Prognosis

• The clinical course of acute sciatica is generally favorable, with most pain and related disability improving within 2-4 weeks with or without treatment 6, 7
• Patient expectations of benefit from treatment may influence outcomes and should be considered when choosing interventions 1