For Sciatica, Medication May Not Be the Answer

New guidelines from the UK discourage the use of medication for sciatica. What do North American spine specialists think? Find out here.

If the U.K.-based National Institute for Health and Care Excellence (NICE) has its way, using medication for sciatica will become less common. In a set of just-released recommendations, NICE has updated its 2016 guidelines with very specific language that discourages the use of multiple classes of drugs. These guidelines bring up the question: Will North American spine societies adopt similar recommendations?

Medication for sciaticaIs medication the right treatment for your sciatica? Some guidelines are saying "no." Some healthcare practitioners say that’s not a bad approach to sciatica treatment. “Western medicine has done a poor job with back pain recently,” says Matthew Sedgley, MD, a sports medicine physician with MedStar Orthopeadic Institute, based out of Baltimore, MD. “I like that the guidelines emphasize physical therapy.”

Specifically, the draft guidelines say that people “with acute or chronic sciatica should not be offered gabapentinoids [a class of drugs originally designed to treat seizures], other antiepileptics, oral corticosteroids or benzodiazepines,” and also recommends against opioids. The guidelines add that “there is no evidence on the use of antidepressants for sciatica, although it is recognized that they are prescribed for this condition and may be of benefit in some people.”

Medication for Sciatica

Medication is among the courses of action that you can try for sciatica. Options include nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, corticosteroids, and benzodiazepines. Opioids, while long overprescribed for various types of pain in the United States, don’t have much application for nerve pain like sciatica and aren’t much of a go-to for most prescribing physicians.

A 2017 trial of pregabalin—a type of gabapentinoid—that appeared in New England Journal of Medicine, suggested that the drug did not significantly reduce the intensity of leg pain associated with sciatica, nor did it significantly improve other outcomes, as compared with a placebo, over a course of eight weeks. In addition, the incidence of adverse events such as confusion, dizziness, and sleepiness was significantly higher in the pregabalin group than the placebo group.

For patients, then, the question becomes: How do I best treat sciatica, and are there any medications worth trying for sciatic nerve pain?

Sciatica Treatment Options

Faheem Akram Sandhu, MD, director of Spine Surgery at MedStar Georgetown Hospital, says that when it comes to acute pain, he does recommend medications like over-the-counter NSAIDs and of late, gabapenitoids. “I’ve also offered brief courses of oral steroids when someone has acute pain,” he says. “These are all typical approaches.”

Dr. Sandhu agrees, however, that the side effects of the gabapentinoids likely outweighs the benefits and he prescribes them only for acute pain, and even then, sparingly. “Another approach is to inject the nerve with steroids,” he explains. “My impression is that oral steroids are mildly beneficial, but rarely the solution.”

A physician or physical therapist can determine the difference between true sciatica and low back pain, says Gene Shirokobrod, DPT, and co-owner of Recharge Modern Health and Fitness, by looking for a “clear pattern of symptoms running down the posterior chain, because that’s where the nerve runs.”

Medication for sciatica PTPhysical therapy for sciatica may be the way to go.Physical Therapy for Sciatica

When he treats a patient with sciatica, Dr. Shirokobrod looks first to determining what aggravates the condition and in what position the patient might spend a good deal of his or her day. “The patients’ nerves are irritated and sending a ‘danger’ signal to the brain,” he explains. “This might manifest itself as tingling along with the pain—the body will try to protect itself from the pain if it senses the tingling alone.”

Once Dr. Shirokobrod has identified the source of irritation, he works with the patient to desensitize the issue. “This amounts to challenging the nerve in a safe manner,” he says. “How quickly the condition resolves depends on whether it’s acute or chronic. The pan level is higher in acute cases, but it’s usually easier to treat. The faster you get intervention, the better the odds you won’t need additional treatment.”

The first few days of physical therapy aimed at relieving sciatica are designed as an analgesic, says Dr. Shirokobrod, calming the system down. “The body will generally do its work within about four weeks without medication,” he says.

Other Conservative Sciatica Treatments

While Dr. Sandhu is a surgeon, he prefers to treat sciatica nonoperatively whenever possible. “If there’s a significant sign of weakness in the leg or foot due to nerve compression, surgery may be indicated,” he says. “It can become an emergency situation if there is numbness around the groin and it impacts bowel or bladder function.”

Otherwise, says Dr. Sandhu, “We tend to manage sciatica conservatively. If after six to eight weeks of no improvement and a clear correlation with an MRI, then surgery can make sense also.”

As to the new NICE guidelines, Dr. Sandhu says there is value in the U.S. medical system taking them into consideration. “The U.K. has a system that allows them to track interventions and outcomes, so the recommendations are based on data,” he says. “When someone comes into my office, it’s natural to want to help them get out of pain. It’s helpful to have guidelines to follow.”

 

Updated on: 09/16/20
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Physical Therapy to Relieve Sciatica

Sciatica treatment may include passive and active physical therapies to reduce low back and leg pain. Ultrasound, moist heat and massage are types of passive physical therapy, while active physical therapy involves stretches and exercise.
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