Sciatica

The defining feature is pain below the knee following a nerve territory, often with pins and needles, numbness or weakness. Back pain may be present or absent. Pain that stays in the buttock and thigh is usually something else and is managed differently.

Imaging is unhelpful in the first weeks unless there are red flags. Disc bulges are common in people with no pain at all, and an MRI early in the course frequently finds something that was not causing the problem.

The majority of disc-related sciatica improves substantially over a period of weeks without surgery. Herniated disc material shrinks over time, and the larger extrusions often resorb best. This is the single most useful thing for a patient in the acute phase to know.

Surgery gives faster relief of leg pain in the first months for patients who are not improving, but by one to two years the difference between operated and non-operated patients narrows considerably 2. That trade-off — speed now against no operation at all — is the real decision.

Early on: keeping moving, positioning that reduces nerve irritation, and pain control that allows sleep. Bed rest makes outcomes worse and is not advised. Later: restoring lumbar and hip movement, progressive loading, and rebuilding the tolerance needed to sit, drive and lift again.

Traction and spinal decompression are available and some patients find them useful for symptom relief. The evidence that they change the course of the condition is weak, and we do not build a programme around them or present them as a cure.

Recurrence is common. The measures with actual support are maintaining general exercise, keeping trunk and hip strength, avoiding prolonged static postures, and managing weight. Back braces, special mattresses and posture gadgets do not prevent recurrence and we do not sell them as if they do.

Which nerve root is involved, from the pattern of pain, sensation, reflexes and specific muscle strength. Whether weakness is present and whether it is getting worse, because that changes the urgency. How far you can walk and sit before symptoms stop you, timed rather than estimated.

We also check what the pain is doing to sleep and to mood, because both affect recovery and both are treatable alongside the physical problem.

Pain relief exists to make movement possible, not to remove the problem. Simple analgesia and anti-inflammatories help some people; neuropathic agents are sometimes used for nerve pain but their benefit in sciatica is smaller than commonly assumed.

Opioids are not recommended for this. They control acute pain poorly in nerve root problems, and the tolerance and constipation that follow make the rehabilitation harder rather than easier.

An epidural or nerve root injection can reduce severe leg pain enough for rehabilitation to begin. It is a window rather than a cure, and it makes sense only when there is a therapy plan for the weeks that follow.

Surgery is considered when severe leg pain persists despite an adequate conservative course, or when weakness is progressing. It relieves leg pain faster than waiting, though at one to two years the difference between operated and non-operated patients narrows considerably — which is why the decision is about how much longer you can tolerate the current state, not about whether recovery is possible without it 2.

Prolonged sitting loads the lumbar discs and is often the position that provokes symptoms most, which makes desk work and long drives the practical problem for most people. The answer is not a special chair but frequent position change — standing and walking briefly at regular intervals does more than any equipment.

Return to work is staged rather than postponed until pain is gone. Waiting for complete resolution before resuming normal activity is associated with worse outcomes, not better ones.