Initial Treatment of Sciatica
For patients with sciatica, advise them to remain active rather than resting in bed, and initiate NSAIDs as first-line pharmacologic therapy, reserving additional interventions for those who fail to improve with this conservative approach. 1, 2, 3
First-Line Management: Self-Care and Activity Modification
Patients should remain active and avoid bed rest, as staying active is more effective than bed rest for managing radicular symptoms. 1, 3
If severe symptoms necessitate brief bed rest, encourage return to normal activities as soon as possible to prevent deconditioning. 1, 3
Apply superficial heat using heating pads or heated blankets for short-term relief of acute pain. 2, 3
Provide evidence-based self-care education materials (such as The Back Book) to supplement clinical care and promote self-management. 2, 3
First-Line Pharmacologic Therapy
NSAIDs are the preferred first-line medication for sciatic pain, offering superior pain relief compared to acetaminophen. 2, 3
NSAIDs provide better analgesia but carry gastrointestinal, renal, and cardiovascular risks that must be assessed before prescribing. 2, 3
Use the lowest effective dose for the shortest duration, particularly in older patients and those with cardiovascular, renal, or gastrointestinal risk factors. 3
Acetaminophen is an alternative with a more favorable safety profile and lower cost, particularly for patients with NSAID contraindications. 2, 3
Monitor for asymptomatic aminotransferase elevations with acetaminophen at 4 g/day dosing. 1
Additional Pharmacologic Options
Skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) may provide short-term relief when muscle spasm contributes to pain. 1, 3
Gabapentin shows small, short-term benefits for patients with radiculopathy, though it is not FDA-approved for this indication. 4, 1, 3
Tricyclic antidepressants may be effective for neuropathic pain components of sciatica in patients without contraindications. 4, 1, 3
Avoid systemic corticosteroids, as they have not been shown to be more effective than placebo for sciatica. 4, 1, 3
Second-Line Treatment for Persistent Symptoms (After 2-4 Weeks)
Non-Pharmacologic Therapies
For acute sciatica (<4 weeks) that persists despite first-line treatment:
- Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits. 1, 2, 3
For chronic or subacute sciatica (>4 weeks):
Exercise therapy with individual tailoring, supervision, stretching, and strengthening is effective, reducing pain by approximately 10 points on a 100-point scale. 1, 2, 3
Acupuncture as an adjunct to conventional therapy is more effective than sham acupuncture. 1, 2, 3
Massage therapy shows similar efficacy to other effective noninvasive interventions. 1, 3
Cognitive-behavioral therapy provides moderate effects, reducing pain by 10-20 points on a 100-point scale. 1, 3
Intensive interdisciplinary rehabilitation (combining physical, vocational, and behavioral components) is moderately more effective than non-interdisciplinary approaches. 1, 3
Interventional Procedures
Epidural steroid injections should be considered for patients with persistent radicular symptoms despite conservative therapy. 1, 2, 3
Epidural steroids may be beneficial for subgroups with nerve root compression, though evidence quality varies. 5
Third-Line Treatment for Refractory Cases
Surgical consultation should be considered for patients with progressive neurological deficits or symptoms persisting beyond 6-8 weeks with confirmed disc herniation. 2, 3
Discectomy is effective in the short term, but long-term outcomes are not superior to prolonged conservative care. 3, 6
Immediate surgical intervention is required for cauda equina syndrome, which is a medical emergency. 1, 3
Spinal cord stimulation can be considered in multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. 1, 3
Critical Pitfalls to Avoid
Do not order routine imaging for initial evaluation unless red flags are present (cauda equina syndrome, progressive neurological deficits, suspected infection, or malignancy), as imaging does not improve outcomes and may lead to unnecessary interventions. 1, 3
Avoid prolonged bed rest, which leads to deconditioning and potentially worsens symptoms. 1, 3
Reserve extended medication courses only for patients clearly showing continued benefits without major adverse events. 4, 1, 3
The natural course of acute sciatica is generally favorable, with most pain and disability improving within 2-4 weeks with or without treatment. 7, 6