Initial Management of Sciatica

Start with staying active and NSAIDs—bed rest is contraindicated and systemic corticosteroids are ineffective. 1, 2

First-Line Treatment: Conservative Management (Weeks 0-6)

Advise patients to remain active rather than bed rest, as this is more effective for managing radicular symptoms and prevents deconditioning 1, 2, 3
If severe symptoms require brief bed rest, return to normal activities as soon as possible 1, 2
Provide evidence-based self-care educational materials to supplement clinical care 1, 2
Apply superficial heat using heating pads for short-term pain relief in acute presentations 1, 2

NSAIDs are the preferred first-line medication, offering superior pain relief compared to acetaminophen, though they carry gastrointestinal, renal, and cardiovascular risks 2
Acetaminophen is an alternative with better safety profile and lower cost for patients with NSAID contraindications 2, 3
Before prescribing NSAIDs, assess cardiovascular and gastrointestinal risk factors and use the lowest effective dose for shortest duration 1, 2
Systemic corticosteroids (like Medrol dose packs) are explicitly not recommended—they have not demonstrated superiority over placebo and expose patients to unnecessary risks including hyperglycemia, bone loss, and immunosuppression 1, 2

Gabapentin shows small, short-term benefits in patients with radiculopathy and may be considered for neuropathic pain features 1, 2, 3
Tricyclic antidepressants provide pain relief in patients with chronic sciatica and neuropathic components without contraindications 1, 2
Skeletal muscle relaxants (cyclobenzaprine, tizanidine, metaxalone) offer short-term relief when muscle spasm contributes to pain 1, 2

Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits 1, 2, 3
Combining spinal manipulation with exercise or advice slightly improves function at 1 week compared to exercise alone 2

Exercise therapy with individual tailoring, supervision, stretching, and strengthening shows small to moderate effects with 10-point reduction on 100-point pain scale 1, 2
Motor Control Exercise focusing on spinal stabilizing muscles demonstrates moderate pain reduction with functional improvements 2
Cognitive-behavioral therapy and progressive relaxation provide moderate effects with 10-20 point reduction on 100-point pain scale 1, 2
Acupuncture should be used as an adjunct to conventional therapy, showing superiority over sham acupuncture 1, 2
Massage therapy demonstrates similar efficacy to other effective noninvasive interventions 1, 2
Intensive interdisciplinary rehabilitation combining physical, vocational, and behavioral components is moderately more effective than non-interdisciplinary approaches 1, 2

Epidural steroid injections (fluoroscopically guided) may be considered for persistent radicular symptoms despite adequate conservative therapy, with moderate to strong evidence for disc herniation-related pain 1, 2, 3
Medial branch blocks for facet-mediated spinal pain contributing to symptoms 1, 2
Sacroiliac joint injections for symptomatic relief when joint dysfunction contributes 1, 2
Botulinum toxin as adjunct for piriformis syndrome when it contributes to sciatic symptoms 1, 2
Radiofrequency ablation (conventional thermal or water-cooled) for facet-related pain or chronic sacroiliac joint pain 1
Spinal cord stimulation for multimodal treatment of persistent radicular pain unresponsive to other therapies 1, 2

Consider surgical consultation for progressive neurological deficits or failure of 6-8 weeks of conservative treatment 1, 3
Immediate surgical referral is mandatory for cauda equina syndrome (urinary retention has 90% sensitivity), which is a medical emergency 2, 3

Cauda equina syndrome: urinary retention, fecal incontinence, or bladder dysfunction 2, 3
Progressive motor deficits at multiple levels 2, 3
Suspicion of infection: fever, intravenous drug use, recent infection 2
Suspicion of malignancy: history of cancer, unexplained weight loss, age >50 years with new-onset pain 2, 3
Vertebral compression fracture: advanced age, osteoporosis history, steroid use 2

Avoid routine imaging for acute sciatica without red flags—it does not improve outcomes and may lead to unnecessary interventions 4, 2, 3
MRI is the preferred imaging modality when indicated, providing superior soft tissue contrast without ionizing radiation 2, 3, 5
Consider MRI or CT only after 6-8 weeks of conservative treatment if patient is a potential candidate for surgery or epidural steroid injection 4, 2, 3
Imaging findings must be correlated clinically—bulging discs without nerve root compromise are frequently nonspecific and seen in asymptomatic individuals 4, 2

Never recommend prolonged bed rest—it leads to deconditioning and worsens outcomes compared to staying active 1, 2, 3
Do not prescribe systemic corticosteroids—they lack efficacy and cause harm, particularly problematic in diabetic patients due to hyperglycemia 1, 2
Do not order routine imaging in the first 6-8 weeks without red flags—this increases healthcare utilization without clinical benefit 4, 2
Extended medication courses should be reserved only for patients demonstrating continued benefits without major adverse events 1, 2
Do not overlook psychosocial factors—emotional distress and psychosocial factors are stronger predictors of outcomes than physical examination findings or pain severity 2, 3
Avoid passive modalities (TENS, ultrasound, taping) as standalone treatments—insufficient evidence supports their use 2