From the Guidelines
For patients with sciatica, clinicians should consider the addition of nonpharmacologic therapy with proven benefits, such as spinal manipulation for acute low back pain, and intensive interdisciplinary rehabilitation for chronic or subacute low back pain. Management of sciatica typically begins with conservative approaches before considering more invasive options. Initial treatment includes rest for 1-2 days, followed by gradual return to activity, along with over-the-counter pain medications such as NSAIDs. However, according to the study by 1, there is little evidence to guide specific recommendations for medications for patients with sciatica.
Nonpharmacologic Therapy
- Spinal manipulation is recommended for acute low back pain, as it has proven benefits 1.
- Intensive interdisciplinary rehabilitation is recommended for chronic or subacute low back pain, as it has proven benefits 1.
- Physical therapy focusing on core strengthening, stretching, and proper body mechanics should be started early.
Pharmacologic Therapy
- Gabapentin is associated with small, short-term benefits in patients with radiculopathy, but has not been directly compared with other medications or treatments 1.
- Benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief, but are also associated with risks for abuse, addiction, and tolerance 1.
- Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1.
Invasive Options
- Epidural steroid injections targeting the affected nerve root may be considered if conservative measures fail to provide relief after 6-8 weeks.
- Surgery (microdiscectomy) is generally reserved for cases with persistent severe pain, progressive neurological deficits, or cauda equina syndrome. Sciatica often results from compression or irritation of the sciatic nerve, commonly due to herniated discs, spinal stenosis, or piriformis syndrome. Most cases (80-90%) improve within 6-12 weeks with conservative management, so a stepwise approach balancing pain control with functional improvement is recommended.
From the Research
Management of Sciatica
- The management of sciatica can be approached through various methods, including conservative treatment, physiotherapy interventions, and pharmacological interventions 2, 3, 4, 5, 6.
- Conservative treatment, which includes methods such as traction, exercise therapy, and drug therapy, has shown varying degrees of effectiveness in managing sciatica, with some studies suggesting that epidural steroids may be beneficial for subgroups of nerve root compression 2.
- Physiotherapy interventions are often prescribed as first-line treatment for people with sciatica, but their effectiveness remains controversial, with some studies showing no significant difference in pain and disability outcomes between physiotherapy and control interventions 5.
- Pharmacological interventions, such as non-steroidal anti-inflammatory drugs (NSAIDs), have been shown to have low to very low-level evidence for pain reduction in people with sciatica, although they may be more effective than placebo for global improvement 6.
- Gabapentin, an anticonvulsant, has been shown to be effective in treating sciatica in some case reports, but further research is needed to validate its benefit in the treatment of sciatica 3, 4.
Treatment Options
- Conservative treatment:
- Traction
- Exercise therapy
- Drug therapy
- Epidural steroids
- Physiotherapy interventions:
- Various forms of physical therapy
- Pharmacological interventions:
- NSAIDs
- Gabapentin
- Other analgesic and adjuvant pain drugs