What is Sciatica?

From the Guidelines

For managing sciatica, I recommend a multi-faceted approach including both non-medication and medication options, prioritizing conservative treatments and physical therapy for long-term management, as supported by the American College of Physicians and the American Pain Society guidelines 1.

Key Recommendations

• Start with conservative treatments like rest for 1-2 days, followed by gentle stretching exercises focusing on the lower back, hamstrings, and piriformis muscle.
• Apply ice packs for 20 minutes every 2-3 hours during acute pain, then switch to heat therapy after 48-72 hours.
• For medication, begin with over-the-counter NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (220-500mg twice daily).
• If pain persists, prescription medications such as muscle relaxants (cyclobenzaprine 5-10mg three times daily) or short-term oral corticosteroids may help.

Non-Pharmacologic Interventions

• Spinal manipulation administered by providers with appropriate training is associated with small to moderate short-term benefits for acute low back pain 1.
• Intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation are recommended for chronic or subacute low back pain 1.

Important Considerations

• Most sciatica cases resolve within 4-6 weeks with conservative approaches.
• The pain occurs when the sciatic nerve becomes compressed or irritated, commonly due to a herniated disc, bone spur, or spinal stenosis, which is why addressing inflammation and muscle tension while improving spinal alignment is essential for relief.
• Extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events 1.

From the Research

Sciatica Treatment Options

• The effectiveness of various treatment options for sciatica, including conservative therapies, physiotherapy interventions, and drug therapies, has been investigated in several studies 2, 3, 4.
• A systematic review of conservative treatment of sciatica found that the natural course of the condition seems to be favorable, but the additional value of many conservative therapies remains controversial 2.
• Physiotherapy interventions are commonly prescribed as first-line treatment for people with sciatica, but their effectiveness remains uncertain due to high risk of bias and heterogeneity in the available evidence 3.

Drug Therapies for Sciatica

• A systematic review and meta-analysis of drugs for relief of pain in patients with sciatica found that the evidence to judge the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and opioid analgesics ranged from moderate to low quality 4.
• The review found that most of the pooled estimates did not favor the active treatment over placebo, but some benefits were seen with corticosteroids and the anticonvulsant gabapentin in the short term 4.
• Muscle relaxants have been used to treat acute and chronic pain, but their efficacy and safety are uncertain due to limited evidence and high risk of bias in available studies 5, 6.

Efficacy and Safety of Muscle Relaxants

• A systematic review and meta-analysis of muscle relaxants for adults with non-specific low back pain found that non-benzodiazepine antispasmodics might provide small reductions in pain intensity at or before two weeks, but might also increase the risk of an adverse event 6.
• The review highlighted the need for large, high-quality, placebo-controlled trials to resolve uncertainty about the clinical efficacy and safety of muscle relaxants 6.