What is the recommended treatment for sciatica?

Treatment of Sciatica

NSAIDs are the first-line medication for sciatica, combined with advice to remain active rather than bed rest, with superficial heat application for short-term pain relief. 1, 2

First-Line Treatment Approach

Activity Modification and Self-Care

• Advise patients to stay active rather than rest in bed—this is more effective for managing radicular pain and prevents deconditioning. 1, 3, 2
• If severe symptoms necessitate brief bed rest, return to normal activities as soon as possible to avoid worsening outcomes. 1, 3
• Apply superficial heat using heating pads or heated blankets for short-term relief of acute pain (effective at 4-5 days). 1, 2
• Provide evidence-based educational materials on self-care to complement clinical management. 1, 2

Pharmacologic Management

• Start with NSAIDs as the preferred first-line medication—they provide superior pain relief compared to acetaminophen, though they carry gastrointestinal, renal, and cardiovascular risks. 1, 2
• Before prescribing NSAIDs, evaluate cardiovascular and gastrointestinal risk factors, and use the lowest effective dose for the shortest duration. 1
• Use acetaminophen as an alternative for patients with NSAID contraindications (active peptic ulcer disease, significant GI bleeding risk, cardiovascular disease)—it has a more favorable safety profile and lower cost despite being slightly less effective. 1, 2
• Do not prescribe systemic corticosteroids—they have not been shown to be more effective than placebo and expose patients to unnecessary risks including hyperglycemia, bone loss, immunosuppression, and infection. 1, 3

Medications to Avoid

• Avoid oral corticosteroids like Medrol entirely for sciatica—they lack efficacy and are especially problematic in diabetic patients due to significant blood glucose elevation. 1

Second-Line Treatment for Persistent Symptoms (After 4-6 Weeks)

Non-Pharmacologic Therapies

• Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute sciatica (<4 weeks). 1, 3, 2
• Exercise therapy with individualization, supervision, stretching, and strengthening is effective for chronic sciatica (>12 weeks), with small to moderate pain reduction of 10 points on a 100-point scale. 1, 3, 2
• Acupuncture should be used as an adjunct to conventional therapy for chronic sciatica—it is more effective than sham acupuncture. 1, 3, 2
• Massage therapy provides moderate effectiveness comparable to other proven interventions for chronic sciatica. 1, 3, 2
• Cognitive-behavioral therapy is useful for managing chronic pain, with 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 for chronic sciatica. 1, 3, 2

Additional Pharmacologic Options for Neuropathic Features

• Consider gabapentin for small, short-term benefits in patients with radiculopathy and neuropathic pain components. 1, 3
• Tricyclic antidepressants are an option for pain relief in patients with chronic sciatica and neuropathic features without contraindications. 1, 3
• Skeletal muscle relaxants (cyclobenzaprine, tizanidine, metaxalone) may provide short-term relief when muscle spasm contributes to pain. 3

Third-Line Treatment for Refractory Symptoms

Interventional Procedures

• Epidural steroid injections (fluoroscopically guided caudal, lumbar interlaminar, or lumbar transforaminal) should be considered for patients with persistent radicular symptoms despite adequate conservative therapy. 1, 3, 2
• Medial branch blocks are used for facet-mediated spinal pain contributing to sciatica. 1, 3, 2
• Sacroiliac joint injections provide symptomatic relief when sacroiliac joint dysfunction contributes to symptoms. 1, 3, 2
• Botulinum toxin is used as an adjunct for piriformis syndrome when it contributes to sciatic symptoms. 1, 3, 2
• Radiofrequency ablation (conventional thermal for facet-related pain, water-cooled for chronic sacroiliac joint pain) is used for specific types of spinal pain. 1, 3, 2
• Spinal cord stimulation is used in multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. 1, 3, 2

Surgical Consultation

• Consider surgical consultation for patients with progressive neurological deficits or symptoms persisting beyond 6-8 weeks with confirmed disc herniation on MRI. 2
• Immediate surgical intervention is required for cauda equina syndrome (urinary retention has 90% sensitivity). 1

Diagnostic Pearls

Clinical Examination

• The straight leg raise test has high sensitivity (91%) but modest specificity (26%) for disc herniation. 1, 2
• The crossed straight leg raise test is more specific (88%) but less sensitive (29%). 1, 2
• Evaluate knee strength and reflexes (L4 root), great toe dorsiflexion and foot strength (L5 root), and plantar flexion strength and ankle reflexes (S1 root). 1
• Over 90% of symptomatic disc herniations occur at L4/L5 and L5/S1 levels. 1

Imaging Indications

• Avoid routine imaging for acute sciatica without red flags—it does not improve outcomes and may lead to unnecessary interventions. 1, 3, 2
• MRI is the preferred imaging modality when indicated, providing superior soft tissue contrast without ionizing radiation. 1, 2
• Consider MRI or CT only for persistent symptoms if the patient is a potential candidate for surgery or epidural steroid injection. 1, 3

Red Flags Requiring Immediate Evaluation

• Cauda equina syndrome (urinary retention, saddle anesthesia). 1
• Progressive neurological deficits. 1, 3
• Suspicion of infection (fever, intravenous drug use, recent infection). 1
• Suspicion of malignancy (history of cancer, unexplained weight loss, age >50 years, lack of improvement after 1 month). 1
• Vertebral compression fracture (advanced age, history of osteoporosis, steroid use). 1

Critical Pitfalls to Avoid

• Do not recommend prolonged bed rest—it is less effective than staying active and can lead to deconditioning. 1, 2, 4, 5
• Do not rely excessively on imaging findings without clinical correlation—bulging discs without nerve root compromise are frequently nonspecific and do not correlate with symptoms. 1
• Do not neglect to evaluate psychosocial factors, which are stronger predictors of outcomes than physical examination findings or pain severity. 1
• Extended courses of medication should be reserved for patients who clearly demonstrate continued benefits without major adverse events. 1, 3
• Avoid passive modalities (TENS, electrical muscle stimulation, ultrasound, taping) as standalone treatments—they should only supplement active exercise therapy. 1