Treatment

Rest

Most cases of acute sciatica associated with herniated discs can be managed non-operatively. Although immobilization or bed rest was often recommended for acute sciatica in the past, this has not been shown to improve the overall outcome of the patient. Bracing is another option to immobilize the spine, but this also has not been shown to improve the outcome for patients with sciatica due to disc herniation.

Medications

Most health care providers start treatment with medications in an effort to reduce discomfort in the acute phase. Many physicians will prescribe NSAIDs (Non- Steroidal Anti-Inflammatory Drugs), such as naproxen or ibuprofen. These medications are not recommended for people with gastric ulcers or kidney disease.

Some physicians prescribe a short course (burst) of corticosteroids (e.g., prednisone, methylprednisolone) to target the inflammation associated with a disc herniation. Patients on a brief course of steroids might notice insomnia, agitation, or increased appetite with oral steroids. 

Muscle Relaxers (e.g., cyclobenzaprine, methocarbamol, tizanidine) may be prescribed to treat the painful muscle spasm that often accompanies an acute disc herniation. Other muscle relaxers include benzodiazepines, such as diazepam or lorazepam. Most muscle relaxers have the side effect of drowsiness and therefore should be used with caution.

Opiates include hydrocodone and oxycodone. These medications are available in combination with acetaminophen. These medications may also cause sedation and should not be used while operating a car or other machinery. Opiate analgesics are Schedule II controlled substances, meaning they have a significant potential for abuse and because of that, the federal government regulates how they are distributed.

Tramadol (Ultram) has some actions similar to opiates. This medication is not a controlled substance but is considered to have abuse potential. Common side effects include dizziness, nausea, and somnolence.

Other drugs are used to target the nerve pain associated with sciatica. Nerve pain is often called "neuropathic pain." Tricyclic antidepressants, such as amitriptyline and nortriptyline, are sometimes helpful for nerve pain and for chronic pain. They can be sedating and may be best taken before bed. Anti-epileptic drugs such as gabapentin, pregabalin, and topiramate are also commonly used for neuropathic pain. These medications are also associated with somnolence and dizziness; therefore, dosages should be increased slowly.

Physical Therapy

Exercises under the supervision of a physical therapist can increase core strength and improve posture in an effort to reduce pain and recurrence. Physical therapists can also provide icing and heat modalities to reduce pain and inflammation around the spine. This should only be done in the acute stages. The core muscles include the abdominals to the front of the spine, the paraspinal and gluteal muscles to the rear of the spine, the diaphragm as the roof, and pelvic floor and hip girdle muscles as the floor.

Physical therapists can also provide biomechanical education to train patients to avoid aggravating their condition with everyday activities, such as standing, working at a desk, driving, lifting, and carrying. Physical therapy may be more beneficial for patients with chronic pain than acute pain.

Some physical therapists provide special services. Traction is a technique in which a pulling force (approximately 1.5 times the person's body weight) is applied to stretch soft tissues and to separate joint surfaces with goals to reduce pain and increase function. There is limited evidence showing that physical therapy combined with traction might reduce the size of disc herniations. Traction should be discontinued if pain is worse after treatment.

Manipulation is offered by some manual physical therapists, chiropractors, and osteopaths. The goal of manipulation is to maintain optimal body mechanics and improve motion in areas of the body that are restricted by soft tissues. There is limited evidence to suggest that manipulation can reduce back pain and disability in the first few weeks after onset. Lumbar manipulation seems unlikely to cause harm.

Epidural Steroid Injections

Epidural steroid injections have been used to manage pain associated with an acute disc herniation that does not improve adequately with time, medications, and rest. Interventional pain specialists generally perform these injections, often with fluoroscopic (i.e., x-ray) guidance. The physician guides a needle to the epidural space. This space surrounds the dura, a tough covering that envelops the spinal cord and cerebral spinal fluid. Once the tip of the needle is in the appropriate spot, appropriate placement is confirmed with use of contrast that is visible on x-ray. The flow of the contrast on x-ray assures the physician that the medication will reach the desired location-the epidural space. Then, steroid and local anesthetic is injected. Corticosteroids are used to decrease inflammation and pain. They are not anabolic steroids, which are used to illicitly build muscle strength.

The epidural space may be approached via an intralaminar approach (midline, between vertebrae), transforaminal approach (to the side, directed toward the nerve root), or caudal approach (base of the sacrum). Epidural steroid injections appear to reduce sciatic pain due to disc herniation in the short-term, but probably do not alter the natural history of the disc regression.

Surgery

Generally, surgical intervention is reserved for disc herniations associated with persistent or progressive neurologic deficits, such as weakness. Several studies have suggested that even patients with weakness associated with disc herniation recover equally with surgical and non-surgical management, provided that the weakness is not progressive. Surgery is offered at different rates across the country, with some regions reporting a 20-fold higher rate of surgery for herniated discs when compared to other regions with lower surgery rates. Size of disc herniation does not appear to correlate with the need for eventual surgery. Surgery does not appear to prevent recurrence of disc herniation compared to non-operative management.

There are few instances when surgical decompression after disc herniation is considered a surgical emergency. Any patient with rapidly progressive localized weakness of a lower extremity or symptoms of cauda equina syndrome (e.g., loss of bowel and bladder control) should seek medical attention immediately.

Several surgical procedures are offered. Open laminectomy and discectomy, in which the surgeon makes an incision and removes part of the vertebra and the herniated disc, has been available the longest. This may be combined  with fusion, in which 2 or more vertebrae are fused together to limit movement between vertebrae. Microdiscectomy uses a microscope to perform the discectomy, enabling the surgeon to remove the herniated disc through the smallest incision possible, usually around 2 cm long. Percutaneous lumbar discectomy uses a specialized instrument called a nucleotome that is guided into the herniated disc using x-rays for guidance. The disc material is withdrawn through the nucleotome. While this technique is minimally invasive and can be done under local anesthesia, some surgeons believe that the rate of recurrence may be high because of missed disc fragments.

New technologies

Several new strategies to treat disc herniation have been proposed. These treatments are not considered standard of care but may be available in some areas. One proposed treatment is intravenous injection of infliximab for treatment of acute sciatica lasting 2-4 weeks. Infliximab is an antibody to TNFα, an inflammatory marker thought to be involved in disc herniation. Other proposed procedures include medical ozone injections into disc and around nerve roots, electrothermal disc decompression, and nucleoplasty.