How should sciatica be managed, including conservative measures, pharmacologic therapy, and criteria for epidural steroid injection or surgery?

Sciatica Pain Management

For acute sciatica, advise patients to stay active, prescribe NSAIDs or acetaminophen for short-term pain relief, and reserve imaging for those with red-flag symptoms or persistent symptoms beyond 6 weeks; epidural steroid injections are appropriate only after documented failure of at least 6 weeks of conservative therapy including physical therapy, and surgery should be considered only after 3–6 months of comprehensive conservative management has failed. 1

Initial Assessment and Red-Flag Screening

Perform a focused neurological examination documenting motor strength (hip flexion, knee extension, ankle dorsiflexion/plantarflexion), sensory distribution, and reflexes (patellar, Achilles) to identify the specific nerve root involved. 1

Immediately obtain lumbar MRI without contrast if any of the following red flags are present: 1

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness)
• Progressive or severe neurological deficits
• Suspected malignancy, infection, or vertebral fracture
• Fever, unexplained weight loss, or history of cancer

For patients without red flags, do not order MRI during the first 6 weeks unless symptoms are severe and disabling despite conservative treatment. 1 Early imaging does not improve outcomes and may lead to unnecessary interventions. 1

Conservative Management (First-Line for All Patients)

Activity Modification

Advise patients to remain active and continue normal activities as tolerated—avoid bed rest beyond 1–2 days, as prolonged immobilization worsens outcomes and delays recovery. 1, 2 Staying active provides small but meaningful benefits in functional status and reduces sick leave by approximately 3.4 days compared to bed rest. 2

Pharmacologic Therapy

Start with NSAIDs or acetaminophen for short-term pain relief (days to weeks). 3 These provide the foundation of medical management for acute sciatica. 3

Add skeletal muscle relaxants (cyclobenzaprine 5–10 mg three times daily, or tizanidine 2–4 mg three times daily) for acute pain, but limit duration to 1–2 weeks due to sedation, dizziness, and potential for abuse. 3 Both agents carry risk of hepatotoxicity, though usually reversible. 3

For radicular pain with neuropathic features, initiate gabapentin starting at 300 mg daily and titrate up to 900–1800 mg daily in divided doses. 3 Gabapentin provides small, short-term benefits specifically for radiculopathy. 3 Pregabalin is an alternative but neither agent is FDA-approved for sciatica. 3

Reserve opioids (e.g., oxycodone 5–10 mg every 4–6 hours) only for severe pain unresponsive to NSAIDs and neuropathic agents, and prescribe time-limited courses (≤7–14 days) due to risks of dependence and abuse. 3

Do not prescribe systemic corticosteroids—multiple trials show they are no more effective than placebo for sciatica or low back pain with radiculopathy. 3

Physical Therapy and Exercise

Refer for supervised physical therapy after 2–4 weeks if symptoms persist, requiring documentation of at least 6 weeks of formal therapy with attendance logs before considering epidural injection or surgical referral. 1 Physical therapy should include core strengthening, hamstring stretching, and spine range-of-motion exercises. 4

For acute sciatica (<4 weeks), supervised exercise is not effective and the optimal timing to start therapy is unclear. 3 For subacute or chronic symptoms (>4 weeks), exercise therapy provides moderate benefits. 3

Additional Conservative Options

Spinal manipulation may provide small-to-moderate short-term relief for acute low back pain, but evidence specific to sciatica is insufficient. 3 If used, it should be performed by appropriately trained providers. 3

Acupuncture, massage therapy, and yoga (Viniyoga style) have fair evidence for moderate effectiveness in chronic low back pain, but data specific to sciatica are limited. 3

Superficial heat (heating pads, warm packs) has good evidence for moderate benefits in acute low back pain and is safe for home use. 3

Imaging Criteria

Obtain lumbar MRI without contrast only when: 1

• Red-flag signs are present (order immediately, do not wait)
• Radicular symptoms persist ≥6 weeks despite documented conservative care and the patient is a candidate for epidural injection or surgery
• Progressive neurological deficits develop at any time during the clinical course

MRI without contrast is sufficient for initial assessment of disc herniation, foraminal stenosis, and nerve root compression. 1 Add gadolinium contrast only for patients with prior lumbar surgery presenting with new symptoms, or when infection or malignancy is suspected and non-contrast MRI is nondiagnostic. 1

If MRI is contraindicated (non-MRI-compatible pacemaker, severe claustrophobia unresponsive to sedation), obtain lumbar CT without contrast—it provides >80% sensitivity and specificity for spinal stenosis and foraminal pathology. 1 CT is also preferred for pre-operative bony assessment and when metallic hardware creates MRI artifacts. 1

Epidural Steroid Injection Criteria

Consider epidural steroid injection only after all of the following criteria are met: 5

1. Documented failure of ≥6 weeks of conservative therapy including physical therapy (with attendance logs), NSAIDs, and neuropathic agents (gabapentin or pregabalin). 5

2. MRI confirmation of nerve root compression (disc herniation, foraminal stenosis) that anatomically correlates with the patient's radicular symptoms. 5 Pain must radiate below the knee into the foot and toes. 5

3. Pain severity ≥4/10 causing functional limitation despite conservative treatment. 5

4. Absence of red-flag conditions requiring urgent surgical evaluation. 5

Do not perform epidural injections for: 5

• Non-radicular axial back pain (facet arthropathy, sacroiliac joint pain)
• Spinal stenosis without radiculopathy
• Mechanical low back pain without nerve root compression

Technique requirements: 5

• All epidural injections must be performed under fluoroscopic guidance to ensure proper needle placement and minimize complications. 5
• Transforaminal approach carries higher risk than interlaminar approach and requires specific informed consent regarding serious complications (dural puncture, infection, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, retinal complications, and rare catastrophic events including paralysis and death). 5

Repeat injection criteria: 6

• Repeat epidural injection is appropriate only if the initial injection resulted in ≥50% pain relief lasting ≥2 weeks. 6 Do not repeat injections based solely on patient request without objective evidence of prior benefit. 6

Expected outcomes: 5

• Epidural steroid injections provide short-term relief (2 weeks to 3 months) in approximately one-third of patients. 5 They do not alter the long-term natural history of sciatica. 5

Surgical Referral Criteria

Refer to spine surgery after 3–6 months of comprehensive conservative management has failed, including: 1

• Documented physical therapy ≥6 weeks with attendance logs and therapist progress notes
• Adequate trials of analgesics (NSAIDs, acetaminophen), muscle relaxants, and neuropathic agents (gabapentin) with documented dosages, duration, and patient response
• When appropriate, epidural steroid injection(s) with documented response
• MRI demonstrating pathology (disc herniation, foraminal stenosis) that correlates with clinical symptoms

Earlier surgical referral is justified for: 1

• Cauda equina syndrome (surgical emergency—refer immediately)
• Severe, disabling pain unresponsive to all conservative measures including epidural injections
• Progressive motor weakness (e.g., foot drop worsening over days to weeks)

Surgical outcomes: 7, 8

• Discectomy is effective for short-term symptom relief (6–12 weeks), but long-term outcomes (1–2 years) are similar to prolonged conservative care. 8
• Surgery provides faster relief but does not change the ultimate prognosis. 8
• Shared decision-making is essential in the absence of severe progressive neurological symptoms. 8

Common Pitfalls and Caveats

Do not confuse radicular pain with referred pain. 8 True sciatica involves nerve root compression causing pain radiating below the knee into specific dermatomal distributions, often with numbness, tingling, or weakness. 8 Referred pain from facet joints, sacroiliac joints, or hip pathology may radiate to the buttock or thigh but does not follow dermatomal patterns and does not respond to nerve root–directed therapies. 8

Do not order MRI for acute low back pain without radiculopathy or red flags. 1 Early imaging does not improve outcomes, increases costs, and may identify incidental findings (bulging discs, degenerative changes) that do not correlate with symptoms and lead to unnecessary interventions. 1

Do not perform epidural injections without documented conservative therapy failure. 5 Injections are not first-line treatment and should be reserved for patients who have failed ≥6 weeks of physical therapy and medication management. 5

Do not repeat epidural injections without objective benefit from prior injections. 6 If the first injection did not provide ≥50% pain relief for ≥2 weeks, repeating the injection exposes the patient to procedural risks without demonstrated benefit. 6

Recognize alternative pain generators. 6 If sacroiliac joint provocation tests are positive (≥3 of 6 tests), consider diagnostic sacroiliac joint injection before attributing all symptoms to lumbar radiculopathy. 6 Similarly, evaluate for hip pathology (osteoarthritis, labral tears) in patients with groin or lateral hip pain. 6