Does sciatica go away on its own?

Research shows most people improve over time, with about one third settling within two weeks of onset and about three quarters improving within six to twelve weeks. A smaller number, however, have symptoms that persist or fluctuate over time, and recovery time depends on your individual condition.

Who is more likely to get sciatica?

People whose work or activities involve repeated heavy lifting, bending, or twisting are at higher risk, and it is also more common in dancers and in athletes such as footballers, gymnasts, and tennis players. Prolonged sitting and straining with coughing or sneezing can worsen the pain.

Does sciatica always need surgery?

In most cases, about six weeks of conservative treatment is tried first, including staying active, exercise and core training, and short-term medication. Surgery is only considered when conservative treatment does not help, or when there are warning signs such as severe weakness or loss of bladder or bowel control. The actual management still depends on a physician's individual assessment.

What tests are done when sciatica is suspected?

A physician will first perform a physical and neurological examination of the back, pelvis, and lower limbs, and when needed may arrange lumbar spine X-rays, nerve conduction studies (NCV/EMG), MRI, or CT to clarify the cause of the compression.

Sciatica Explained: From Self-Recovery to Possible Relapse, and the Road Back from Pain

Sciatica is a very broad term that describes nerve pain rather than a specific diagnosis. It appears when a lumbar nerve root is compressed. The actual diagnosis is the cause of that nerve compression — a herniated disc, a slipped disc, or spinal stenosis can all be responsible.

Sciatica refers to radiating pain along the distribution of the lumbosacral nerve roots (L4, L5, S1, S2, or S3). It usually produces symptoms down the back or outer side of the lower limb, extending toward the ankle or foot, and is typically described as electric, burning pain accompanied by numbness and tingling. Depending on how severely the nerve root is compressed, there may be weakness in the muscles supplied by that root.

Epidemiology

In people under 40, sciatica is usually caused by a herniated disc, whereas in older adults it is usually caused by bone spurs and arthritis. Low back pain is extremely common in both the general and the athletic population.
Men and women are affected equally, with no sex difference. In men it usually occurs in the 40s, and in women it usually occurs between the ages of 50 and 60.
It occurs in about 5% of the population, and 10 to 25% of people have symptoms lasting more than six weeks.
A common cause of sciatica or radicular pain is direct mechanical compression of the affected nerve root by a herniated disc and/or chemical irritation of the nerve root by chemical substances, often called radiculitis. L5 and S1 are the most commonly affected nerve roots (90%).
Sciatica is usually unilateral, typically caused by a posterolateral disc herniation or by foraminal narrowing from degenerative arthritis of the spine. In cases of central disc herniation, lumbar spinal stenosis, and spondylolisthesis, bilateral pain may occur. There are also other possibilities involving gynecological, pelvic floor, gluteal, and piriformis compression.
Expected recovery time: within two weeks of onset, 33% of patients improve on their own, and up to 75% may improve on their own within six to twelve weeks. However, research has also found that 8% of patients do not improve, and 23% have symptoms that persist and fluctuate over time; another study found that about 20% of people still have symptoms after an acute flare of back pain, and 3% have still not returned to work after one year.

Risk factors

Occupations or activities that require repeated lifting of heavy objects, bending, or twisting movements.
It can occur in manual workers or in dancers and athletes (for example football, gymnastics, tennis).
Flexion movements, twisting, prolonged sitting, the Valsalva maneuver (coughing, sneezing, straining during bowel movements), and occasionally prolonged standing can aggravate the pain.

Physical examination

A thorough physical examination of the back, pelvis, and lower limbs should be performed, including a detailed neurological examination.
Visual inspection of the lower back and lower limbs, and gait examination.
Palpation of the lower back, sacrum, and hip.
Range of motion of the lower back and lower limbs.
Confirm areas of sensory loss.
- L4: anteromedial calf, medial ankle.
- L5: lateral calf, the dorsal web space of the foot between the big toe and the second toe.
- S1: posterior calf, lateral heel.
Confirm movements that are weak.
- L4: ankle dorsiflexion.
- L5: big toe extension.
- S1: ankle plantarflexion.

Diagnostic tools

Lumbar spine and pelvis X-rays.
Nerve conduction studies NCV/EMG.
MRI.
CT.

Early conservative treatment

A six-week course of conservative treatment should be tried first, unless red flag warning signs appear.
Anti-inflammatory painkillers (NSAIDs): compared with placebo they show possible improvement, but the benefit of painkillers for sciatica is uncertain and they may cause adverse effects; use them only for the short term and in very small amounts (measured in weeks, not months), at the lowest possible dose.
Oral corticosteroids: a short five-day course appears to improve function, but may not improve pain.
Stay active and avoid lying in bed all the time, because excessive rest can make other parts of the body feel unwell. Find a comfortable position, stay as active as possible, and this helps reduce inflammation.
To gain improvement, both aerobic and core strengthening are essential; exercise can reduce the intensity of leg pain in the short term, although the effect may be small.
Epidural corticosteroid injection can improve pain in the short term but may not affect long-term outcomes. NICE guidance suggests its use in patients with acute, severe sciatica who would otherwise be considering surgery; an epidural injection of local anesthetic and corticosteroid into the region of the lumbar nerve root can relieve symptoms.
Lumbar traction, particularly when low back pain is prominent, shows no advantage in current research and literature reviews.
Acupuncture has been proposed for persistent sciatic discomfort, but its efficacy is not yet fully supported.

Surgery

Patients with a lumbar disc herniation who do not respond to conservative treatment should be considered for lumbar decompression and discectomy.
Open microdiscectomy is one of the common surgical approaches, and minimally invasive techniques such as endoscopic surgery are often used.
In the absence of severe intractable pain, neurological deficit, and/or serious disease, immediate surgery should be avoided; surgery can relieve pain more quickly and speed recovery, but it is appropriate to delay surgery to see whether the pain will improve.
If there is a large disc rupture into the spinal canal that compresses the cauda equina, causing bladder or bowel sphincter dysfunction, immediate surgery is recommended.

Follow-up education and monitoring

Quitting smoking and losing weight are beneficial: smoking, obesity, and modifying physical labor are reversible factors that reduce a first episode of sciatica.
Exercise and core stability are the most important foundation of treatment; avoid long-term use of painkillers.

References

Sciatica - OrthoInfo - AAOS
BMJ. 2019 Nov 19:367:l6273. doi: 10.1136/bmj.l6273.
BMJ. 2013 Mar 20:346:f1716. doi: 10.1136/bmj.f1716.
N Engl J Med. 2015 Mar 26;372(13):1240-8. doi: 10.1056/NEJMra1410151.
N Engl J Med. 2020 Mar 19;382(12):1093-1102. doi: 10.1056/NEJMoa1912658.