What is the management of bilateral sciatica due to a herniated intervertebral disc (IVD)?

From the Guidelines

Bilateral sciatica due to herniated disc should be initially managed with a combination of noninvasive treatments, including medication and physical therapy, before considering interventional procedures like epidural steroid injections or surgery, as the natural history of lumbar disc herniation with radiculopathy often shows improvement within the first 4 weeks with conservative management 1.

Initial Management

• Pain control should focus on NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks.
• Muscle relaxants such as cyclobenzaprine (5-10mg three times daily) can be used for muscle spasms.
• A short course of oral steroids like prednisone (starting at 60mg daily and tapering over 5-7 days) may help reduce inflammation in cases of severe pain.

Diagnostic Approach

• Magnetic resonance imaging (MRI) is preferred over CT for evaluating patients with persistent back and leg pain due to its better visualization of soft tissue, vertebral marrow, and the spinal canal, and lack of ionizing radiation 1.
• MRI or CT should be considered for patients who are potential candidates for surgery or epidural steroid injection, especially if there are signs or symptoms of radiculopathy or spinal stenosis.

Physical Therapy and Lifestyle Modifications

• Physical therapy should begin within 1-2 weeks, focusing on core strengthening, stretching exercises, and proper body mechanics.
• Patients should maintain moderate activity while avoiding positions that worsen pain.

Interventional Procedures

• Epidural steroid injections may be considered if conservative treatment fails after 6-8 weeks.
• Surgery, such as microdiscectomy or laminectomy, is typically reserved for cases with progressive neurological deficits, cauda equina syndrome, or persistent severe pain despite conservative measures 1.

Special Considerations for Bilateral Sciatica

• Close monitoring for bladder/bowel dysfunction or progressive weakness is essential due to the potential for more serious neurological compromise.
• Most patients improve with conservative management as the herniated disc material is gradually resorbed by the body, reducing pressure on nerve roots.

From the Research

Management of Bilateral Sciatica due to Herniated Disc

• The management of bilateral sciatica due to herniated disc can be approached through either surgical or conservative methods, with the choice of treatment depending on various factors such as the duration and severity of symptoms, and the presence of neurological deficits 2, 3.
• A systematic review of randomized controlled trials found that early surgery in patients with 6-12 weeks of radicular pain leads to faster pain relief compared to prolonged conservative treatment, but there were no differences after 1 and 2 years 2.
• Another study found that surgical treatment demonstrated significant improvement in back pain, while conservative treatment was associated with a significant reduction in leg pain and improvement in mental and physical health outcomes 3.
• The effectiveness of different surgical techniques, such as open discectomy, microscopic discectomy, and tubular discectomy, has also been compared in several studies, but the evidence is limited and no firm conclusions can be drawn regarding their effectiveness 4.

Surgical Techniques

• Microscopic discectomy results in a significantly longer operation time and shorter incision compared to open discectomy, but did not find any clinically relevant superiority of either technique on clinical results 4.
• The comparison of tubular discectomy versus microscopic discectomy for back pain and surgical duration showed conflicting results, highlighting the need for large, high-quality studies to examine the effectiveness and cost-effectiveness of these surgical techniques 4.

Conservative Management

• Conservative treatment, including epidural injections, can be an effective approach for managing bilateral sciatica due to herniated disc, particularly in cases where surgery is not immediately necessary 2, 3.
• A meta-analysis of clinical trials found that conservative treatment was associated with a significant reduction in leg pain and improvement in mental and physical health outcomes compared to surgical intervention 3.