What is the recommended initial management for an adult with left‑sided sciatica and no NSAID contraindications?

Treatment for Left-Sided Sciatica

NSAIDs are the recommended first-line pharmacological treatment for acute left-sided sciatica in adults without NSAID contraindications, prescribed at the lowest effective dose for the shortest necessary duration. 1

Initial Pharmacologic Management

First-Line: NSAIDs

• NSAIDs provide superior pain relief compared to acetaminophen, with acetaminophen providing roughly 10 mm less pain relief on a 100-mm visual analogue scale. 1
• No specific NSAID is superior to another; choose based on patient risk factors and availability. 1, 2
• Common regimens include:
  • Ibuprofen 400-800 mg every 6-8 hours 1
  • Naproxen 500 mg twice daily 1
• Before prescribing NSAIDs, evaluate cardiovascular risk (prior myocardial infarction, hypertension) and gastrointestinal risk (age >65 years, history of ulcer disease, concurrent corticosteroid use). 1

Alternative if NSAIDs Contraindicated

• If NSAIDs are contraindicated, use acetaminophen up to 4 g daily, acknowledging its inferior analgesic effect. 1
• Monitor for asymptomatic liver enzyme elevations when using maximum-dose acetaminophen, even in otherwise healthy individuals. 1

Non-Pharmacologic Management

Activity and Self-Care

• Encourage patients to stay active and resume normal activities as soon as possible; early activity is more effective than bed rest for relieving sciatica symptoms. 1
• If brief bed rest is unavoidable for severe symptoms, resume activity within days rather than weeks. 1
• Apply heat (heating pads or blankets) for short-term symptomatic relief. 1
• Recommend a medium-firm mattress over a very firm mattress if considering mattress change. 1

Treatments to Avoid

Systemic Corticosteroids

• Do not prescribe systemic corticosteroids (oral or parenteral) for acute sciatica; three high-quality randomized trials showed no clinically significant benefit compared with placebo. 1

Muscle Relaxants

• Routine use of muscle relaxants for sciatica is not recommended because specific efficacy data are lacking. 1
• Tizanidine combined with NSAIDs has shown greater short-term pain relief than NSAIDs alone in low-back-pain trials, but it raises the risk of central nervous system adverse events (relative risk ≈ 2.4). 1

Gabapentin

• Gabapentin lacks sufficient evidence for treating sciatica; only two small trials exist, providing only anecdotal support. 1, 3
• While case reports suggest potential benefit 3, this does not constitute adequate evidence for routine use.

Opioids

• Opioids, including tramadol, should not be used as first-line therapy for acute sciatica; evidence for acute sciatica is limited. 1

Safety Monitoring During NSAID Therapy

• Monitor for gastrointestinal bleeding, recognizing that risk increases with higher NSAID doses. 1
• Monitor cardiovascular status because both COX-2-selective and most non-selective NSAIDs are associated with elevated risk of myocardial infarction. 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor. 4

Clinical Pitfalls to Avoid

• Do not routinely order imaging unless there is evidence of underlying pathology (infection, malignancy) or severe symptoms that do not improve after 6-8 weeks of conservative treatment. 5
• Do not use lumbar support belts; current evidence does not support their benefit for sciatica self-care. 1
• Do not apply cold packs routinely; evidence does not demonstrate a therapeutic advantage. 1
• Recognize that sciatica has a generally favorable natural history, with most pain and disability improving within 2-4 weeks with or without treatment. 6, 5