Sciatica Treatment: Conservative and Surgical Options
Sciatica = Lumbar Radiculopathy (Usually L4–S1)
Pain radiating along the sciatic nerve distribution. 90% due to herniated disc; others: stenosis, spondylolisthesis, piriformis syndrome, tumor.
Conservative Management (First-Line, 6–12 Weeks)
- Activity modification: Avoid bed rest >48h; stay active within pain limits.
- Medications: NSAIDs, acetaminophen; short-course oral steroids (prednisone taper); neuropathic agents (gabapentin, pregabalin) if radicular; muscle relaxants for spasm.
- Physical therapy: McKenzie extension, core stabilization, nerve glides, traction. Evidence supports exercise > passive modalities.
- Epidural steroid injection (ESI): Transforaminal or interlaminar. Short-term relief (1–3 months); may avoid surgery. Fluoroscopic guidance.
- Adjuncts: Acupuncture (modest evidence), massage, TENS, cognitive-behavioral therapy for chronic pain.
Surgical Indications
- Progressive neurologic deficit (weakness, foot drop).
- Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction) – emergency.
- Refractory pain >6–12 weeks despite optimal conservative care.
- Recurrent disc herniation with concordant imaging.
Surgical Options
| Procedure | Indication | Notes |
|---|---|---|
| Microdiscectomy | Single-level herniation | Gold standard; 1–2 cm incision, microscope/tube; 85–90% leg pain relief |
| Laminectomy / Laminotomy | Stenosis, large central herniation | Decompress central canal; may need fusion if instability |
| Foraminotomy | Foraminal stenosis | Enlarge neural foramen; often combined |
| Spinal fusion (PLIF, TLIF, ALIF) | Instability, spondylolisthesis, recurrent herniation | Adds hardware; longer recovery; adjacent segment risk |
| Artificial disc replacement | Single-level DDD with radiculopathy | Preserves motion; select patients |
| Endoscopic discectomy | Contained herniation | Minimally invasive; learning curve |