What is the recommended management for sciatica, including conservative therapy, pharmacologic treatment, and criteria for imaging or surgical referral?

Sciatica Management

For acute sciatica, advise patients to stay active and avoid bed rest, prescribe simple analgesics or NSAIDs for short-term use, and reserve imaging for patients with red flags or those who fail 6 weeks of conservative therapy and are surgical candidates. 1, 2, 3

Initial Assessment and Red Flag Screening

Perform focused history and physical examination to identify:

• Red flags requiring immediate MRI: cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction), progressive or severe neurological deficits, suspected malignancy, infection, or vertebral fracture 2, 3
• Radicular pattern: leg pain radiating below the knee into foot/toes, worse than back pain 4
• Neurological examination: motor weakness, sensory deficits, reflex changes corresponding to specific nerve root levels 1
• Provocative tests: straight leg raise for L5-S1 radiculopathy, though piriformis-specific maneuvers (Freiberg sign, Pace sign) help distinguish non-discogenic causes 5

If red flags are present, obtain MRI lumbar spine without contrast immediately—do not wait 6 weeks. 2, 3

Conservative Management (First-Line for 6 Weeks Minimum)

Activity Modification

• Advise staying active and continuing normal activities as tolerated—this reduces sick leave by 3.4 days and improves functional status compared to bed rest. 6
• Avoid bed rest beyond 1-2 days, as prolonged immobilization worsens outcomes 1, 6

Pharmacologic Treatment

• Start with simple analgesics (acetaminophen) or NSAIDs for short-term pain relief (days to weeks, not months). 1
• Consider skeletal muscle relaxants (cyclobenzaprine, tizanidine) for acute pain, but limit duration due to sedation and abuse potential. 1
• For radiculopathy with neuropathic pain, trial gabapentin or pregabalin—gabapentin shows small short-term benefits specifically for radicular symptoms. 1, 2
• Avoid opioids as first-line therapy; reserve for severe pain unresponsive to other agents, and prescribe time-limited courses only. 1
• Do not use systemic corticosteroids—they are no more effective than placebo for sciatica. 1

Physical Therapy and Exercise

• Refer for formal, supervised physical therapy after 2-4 weeks if symptoms persist—document minimum 6 weeks of therapy with attendance logs before considering surgical referral. 1, 2
• Avoid active exercise programs during severe acute pain; initiate once pain moderates 7

Additional Conservative Options

• Consider epidural steroid injections for radiculopathy from foraminal stenosis after failed oral medications and before surgery. 2
• Spinal manipulation shows small-to-moderate short-term benefits for acute low back pain but limited evidence specifically for sciatica 1

The natural history favors spontaneous improvement within 2-4 weeks for most patients, so aggressive early intervention is unnecessary. 4, 6

Imaging Criteria

When to Order MRI

Obtain MRI lumbar spine without contrast only if: 2, 3

• Red flags are present (immediate imaging)
• Radicular symptoms persist ≥6 weeks despite conservative management AND patient is a surgical or epidural injection candidate
• Progressive neurological deficits develop at any time

MRI Protocol Specifics

• MRI without contrast is sufficient for initial evaluation of degenerative disease and radiculopathy. 3
• Add contrast only for: prior lumbar surgery with new symptoms, suspected infection/malignancy when non-contrast MRI is non-diagnostic 3

CT as Alternative

• If MRI is contraindicated (non-compatible implants, severe claustrophobia) or delayed >2-4 weeks, lumbar CT without contrast is acceptable—it demonstrates >80% sensitivity/specificity for stenosis and foraminal pathology. 3
• CT is preferred for pre-operative bony assessment and when metallic hardware creates MRI artifacts 3

Common pitfall: Do not order MRI for acute low back pain without radiculopathy or red flags—this leads to unnecessary interventions without improving outcomes. 3

Surgical Referral Criteria

Refer to spine surgery if: 2

• Minimum 3-6 months of comprehensive conservative management has failed (documented physical therapy ≥6 weeks, medication trials, epidural injections if appropriate)
• Imaging demonstrates pathology correlating with clinical symptoms
• Patient has persistent functional impairment despite maximal conservative therapy

Exceptions allowing earlier referral: 2

• Progressive motor weakness (e.g., foot drop)
• Cauda equina syndrome (surgical emergency)
• Severe, disabling pain unresponsive to all conservative measures

Critical documentation before surgical consideration: 2

• Physical therapy records with ≥6 weeks formal supervised therapy, attendance logs, therapist progress notes
• Medication trial specifics: agents, dosages, duration, patient response
• Timeline showing 3-6 months conservative management duration
• MRI or CT demonstrating anatomic correlation with symptoms

Pitfall to avoid: Prior spine surgery does not exempt patients from conservative treatment requirements—they still need documented 6-week therapy trial and 3-6 months conservative management before revision surgery. 2

Special Considerations

Sciatica vs. Piriformis Syndrome

• Piriformis syndrome causes non-discogenic sciatica from sciatic nerve compression by the piriformis muscle—suspect when patients have normal neurological exam, negative straight leg raise, and pain with hip flexion/adduction/internal rotation. 5
• Imaging and electrodiagnostics are typically normal; diagnosis is clinical 5
• Treat conservatively first; consider ultrasound-guided piriformis injections for refractory cases 5

Evidence Limitations

Current evidence shows no single conservative intervention (physical therapy, injections, manipulation, medications) is clearly superior to others or even to no treatment for sciatica. 8 This heterogeneity supports a pragmatic approach: try simple, low-risk interventions first (activity, simple analgesics), escalate to physical therapy and neuropathic agents, and reserve imaging/surgery for the minority who fail conservative care or develop red flags.