Course and management in sciatica

In general the clinical course of acute sciatica is favourable and most pain and related disability resolves within two weeks (1)

• about 50% of patients with acute sciatica included in placebo groups in randomised trials of non-surgical interventions reported improvement within 10 days and about 75% reported improvement after four weeks
• in most patients therefore the prognosis is good, but at the same time a substantial proportion (up to 30%) continues to have pain for one year or longer

Patients should be reassured that the symptoms are self limiting and usually disappear without any specific measures. Patients should be advised to stay active and to continue normal daily activities (1).

Early management can therefore be conservative, and extensive investigation is not warranted at first. Primary objective of conservative management is to reduce pain either by analgesics or by reducing pressure on the nerve root. Consensus is that initial treatment is conservative for about 6-8 weeks (1). The mainstays of conservative management are (1):

• explain cause of the symptoms and reassure patients that symptoms usually diminish over time without specific measures
• advise to stay active and continue daily activities; a few hours of bed rest may provide some symptomatic relief but does not result in faster recovery
• prescribe drugs, if necessary, according to four steps: (1) paracetamol; (2) non-steroidal anti-inflammatory drugs; (3) tramadol, paracetamol, or non-steroidal anti-inflammatory drug in combination with codeine; and (4) morphine
• refer to neurosurgeon immediately in cases of cauda equina syndrome or acute severe paresis or progressive paresis (within a few days)
• refer to neurologist, neurosurgeon, or orthopaedic surgeon for consideration of surgery in cases of intractable radicular pain (not responding to morphine) or if pain does not diminish after 6-8 weeks of conservative care

Epidural steroid injections can be considered for patients in the acute phase of the disease (2).

However systematic reviews have examined various treatment options (1):

• trade-off between benefit and harm - bed rest
• likely to be beneficial - staying active, in contrast to bed rest
• unknown effectiveness - analgesics or non-steroidal anti-inflammatory drugs, acupuncture, epidural steroid injections, spinal manipulation, traction therapy, physical therapy, behavioural treatment, multidisciplinary treatment

The following patients should be referred to a specialist for the possibility of surgery

• patients who do not respond to morphine
• if the pain does not improve after 6-8 weeks of conservative therapy (1)

According to Dutch guidelines, surgery should be offered to patients who do not improve after 6 weeks of conservative treatment (3). Surgical procedures aimed at relieving pressure on nerve roots:

• laminectomy
• discectomy
• chemonucleolysis
• percutaneous techniques

NICE state (5):

• consider spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms

Notes:

• early surgery versus prolonged conservative care in patients with sciatica caused by lumbar disc herniation
  • a RCT compared early surgery with prolonged conservative management in patients with sciatica secondary to a herniated lumbar disc (2)
    • early surgery provided a faster rate of pain relief and perceived recovery
    • however, the 1-year outcomes of the surgery group were similar to outcomes in patients who began with conservative treatment and underwent surgery only if symptoms did not improve
  • in the short-term, early surgery reduced disability, leg pain and back pain more than conservative treatment (3)
    
    
• NICE have given guidance on the pharmacological management of sciatica (5). The suggestions from NICE are outlined:
  • do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm
  • do not offer opioids for managing chronic sciatica
  • if a person is already taking opioids, gabapentinoids or benzodiazepines for sciatica, explain the risks of continuing these medicines
    • as part of shared decision making about whether to stop opioids, gabapentinoids or benzodiazepines for sciatica, discuss the problems associated with withdrawal with the person
  • be aware of the risk of harms and limited evidence of benefit from the use of non-steroidal anti-inflammatory drugs (NSAIDs) in sciatica
    • if prescribing NSAIDs for sciatica:
      • take into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age
      • think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
      • use the lowest effective dose for the shortest possible period of time

For NICE guidance regarding management of chronic pain (pain that lasts for more than 3 months) then see linked item.

Reference:

• (1) Koes BW et al. Diagnosis and treatment of sciatica. BMJ. 2007 Jun 23;334(7607):1313-7.
• (2) Stafford MA et al. Sciatica: a review of history, epidemiology, pathogenesis and the role of epidural steroid injection in the management. British Journal of Anaesthesia 2007 99(4):461-473
• (3) Peul WC et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007 May 31; 356:2245-56.
• (4) Peul WC et al. Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ. 2008 Jun 14;336(7657):1351-4.
• (5) NICE (October 2020). Low back pain and sciatica in over 16s: assessment and management