Sciatica: treatment

sciatic nerve

Most sciatica - sharp pain that radiates down the back of your leg - gets better within a few weeks and doesn't result in permanent damage. If your pain doesn't settle down after a few weeks, see your doctor. If you lose control of your bladder or bowels, or you have severe pain, weakness of your muscles or numbness, seek medical attention immediately.

In general, you can help relieve back pain and sciatica by staying active, using pain killers and doing special stretches and exercises. Physiotherapy may be helpful, and surgery may be recommended for people with ongoing problems.

Pain relief for sciatica

Pain relievers can be used to control sciatica pain so that you can stay active, which in most cases will help you get better faster.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (e.g. Advil, Nurofen), are often recommended for sciatica and can reduce pain as well as inflammation. They should be taken at the lowest dose that is effective for the shortest possible time. However, there are side effects associated with these medicines, including an increased risk of peptic ulcers, heart conditions and kidney problems and NSAIDs are not suitable for some people. The risk of side effects is reduced when NSAIDs are given topically (creams or gels applied to the skin).

Paracetamol may be recommended for people who are not able to take NSAIDs. While paracetamol does not reduce inflammation, it may reduce back pain in the short-term and any reduction in pain that allows you to resume activity will be beneficial.

Other medicines

Muscle relaxants may be recommended for a few days in some people with back pain to reduce pain and muscle tension and improve mobility. However, there are significant side effects with these medicines, so they are often not a suitable option.

Tricyclic antidepressants, e.g. amitriptyline, and certain anti-seizure medicines may be used to treat nerve pain in some people. But more evidence is needed to show that these medicines are effective for people with sciatica.

Stay active

Bed rest isn't a good idea for sciatica and lower back pain, and can worsen the problem. Bed rest will cause the muscles that support the spine to start to weaken and your joints may stiffen.

Staying active actually reduces pain and speeds recovery compared with bed rest. While you are likely to experience some pain with activity, it can be reduced by taking pain relievers.

Advice from a physiotherapist on techniques to minimise pain when doing certain activities, such as getting out of bed and moving around, will help you stay active. Be careful to pace yourself when restarting activities.

Swimming or walking are often a good place to start for some gentle exercise. Tai Chi is a gentle movement activity that has been shown to improve low back pain.

For sciatica associated with a herniated disc, doctors generally encourage keeping to your regular activities as much as you can, providing they don’t provoke severe pain.

Stretching and strengthening exercises

Exercise programs can help recovery and may reduce the frequency and length of recurrent episodes of back pain. It may help to see a physiotherapist, who can design an individual exercise programme for you that involves strengthening and stabilisation of the muscles that support the spine, stretching and also aerobic exercise.

Exercises such as Pilates, which correct poor muscle tone and posture and improve core strength and stability of the spine, can help improve back pain and also help to prevent future episodes.

Gentle passive stretching exercises may help to relieve compression in the spine. Specific floor stretches can be helpful.

Some yoga poses may also help relieve sciatica pain. However, note that suitable stretches for sciatica differ depending on the cause of the sciatica. For example, there are specific stretching exercises which are almost always necessary to relieve piriformis syndrome and these differ from the stretches to ease sciatica caused by spinal stenosis.

Massage

It’s not known for sure whether massage improves sciatica, but some people have found it helpful and there is little risk of side effects. Massage may release muscles that have gone into spasm and provide pain relief.

Osteopathy

People with sciatica commonly consult osteopaths to deal with their condition and some people find it helpful to alleviate their symptoms. In terms of scientific studies, most studies to date have looked at osteopathy to treat low back pain in general, not specifically sciatica, so the evidence supporting its use in sciatica is not abundant. However, some doctors do recommend consulting an osteopath or physiotherapist to relieve the pain of sciatica and to undertake a programme to strengthen and condition the lower back.

Physiotherapy

Your doctor may refer you to a physiotherapist for an exercise prescription to strengthen and stabilise your back, and also for help in relieving the pain of sciatica.

Spinal manipulation

There is some evidence showing small to moderate benefits from spinal manipulation (in conjunction with an exercise program) in the treatment of non-specific low back pain and sciatica. However, there are some safety concerns in patients with sciatica with the possibility of doing further damage to herniated discs by manipulating the spine.

People who have osteoporosis or rheumatoid arthritis should avoid spinal manipulation.

Acupuncture

Acupuncture is the insertion of fine needles into the skin at traditional acupuncture points which are believed to sit on meridians which run through the body.

There is a lack of evidence showing that acupuncture is effective in the treatment of sciatica, although some people do gain relief.

Heat or ice packs

Heat packs and ice packs are a simple self-help treatment that may relieve pain and discomfort in people with low back pain.

TENS — Transcutaneous Electrical Nerve Stimulation

TENS is a treatment that uses low voltage electrical currents to relieve pain. More scientific evidence is needed to show if TENS is an effective treatment for sciatica.

PENS — Percutaneous Electrical Nerve Stimulation

PENS is similar to TENS, but with PENS the electrical stimulation is passed through the skin into the soft tissue using probes similar to acupuncture needles. Again, there isn't enough scientific evidence to state that PENS is an effective pain relief for sciatica.

Epidural injections

Cortisone (corticosteroid) injections may be used to treat sciatica pain by helping to suppress inflammation around the irritated nerve. Epidural corticosteroid injections may provide short-term pain relief for people with a herniated lumbar disc or spinal stenosis.

Long-acting local anaesthetics are also sometimes injected with the corticosteroid for pain relief. Sometimes the local anaesthetic injection is given on its own.

A 2-week course of corticosteroid tablets may help improve physical functioning but does not seem to significantly relieve pain in people with a herniated disc.

Chemonucleolysis

Chemonucleolysis is injection of a special enzyme into a herniated disc of the spine. The enzyme dissolves the displaced and protruding (herniated) part of the disc, and so reduces any pressure on the nerve root. It is a precision technique with a potential for allergy and neurological complications and so is not used often. There does not seem to be any evidence to support its use.

Surgery

In people with a herniated disc or spinal canal stenosis who have severe or progressive nerve problems, decompression surgery may be recommended. Some people with severe, persistent sciatica pain may also be referred for surgical treatment.

The type of surgery will depend on the cause of the sciatica. A discectomy is an operation done through an incision in the back to remove parts of a herniated disc that are pressing on a nerve. A microdiscectomy uses a microscope to view the disc and so can be done through a smaller cut in the back.

A laminectomy involves spinal surgery to remove the entire lamina (part of the vertebral bone) and sometimes part of the facet joint in order to make more room for the nerve roots. Nowadays, a laminotomy (which removes only parts of the laminae) is more often used, as it helps keep more stability in the spinal structures.

Long-term outcomes for people with herniated discs are the same in people who have early surgery versus those who try other treatments first.

Your doctor will discuss the risks and benefits of surgery and whether it may be beneficial in your case.

References

1. Low back pain (revised March 2017). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2018 Jul. https://tgldcdp.tg.org.au/ (accessed Dec 2018).
2. BMJ Best Practice. Discogenic low back pain (updated Mar 2018; reviewed Nov 2018). https://bestpractice.bmj.com (accessed Dec 2018).
3. BMJ Best Practice. Spinal stenosis (updated Oct 2018; reviewed Nov 2018). https://bestpractice.bmj.com (accessed Dec 2018).
4. Ropper AH, Zafonte RD. Sciatica. N Engl J Med 2015;372:1240-48. https://www.nejm.org/doi/full/10.1056/NEJMra1410151 (accessed Dec 2018).
5. NICE (National Institute for Health and Care Excellence). Low back pain and sciatica in over 16s: assessment and management. Published Nov 2016. https://www.nice.org.uk/guidance/ng59 (accessed Dec 2018).
6. Almeida M, Saragiotto B, Richards B, Maher CG. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-5. https://www.mja.com.au/journal/2018/208/6/primary-care-management-non-specific-low-back-pain-key-messages-recent-clinical (accessed Dec 2018).
7. RACGP. Clinical Guidelines. Handbook of non-drug interventions. Exercise for chronic low back pain (published Jan 2016). https://www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/musculoskeletal/exercise-for-chronic-low-back-pain (accessed Dec 2018).
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