Primary Care Management of Sciatica Manoj Krishna Spinal Surgeon www.spinalsurgeon.com

Evaluation Rule out Cauda Equina Syndrome Any bladder function change? Any Peri-anal altered sensation? Bilateral Leg pain? Check pulses, hips and abdomen Is Neurology progressive ?( Urgent referral) Could it be non-spinal ?

Analgesia( Pain can be severe) Consider Morphine. MST 20mg BD and Oromorph 10mg 6hourly for breakthrough pain. Continue till acute pain eases( 2-4 weeks) and then switch to Tramadol or Codeine. Paracetamol and Naproxen Gabapentin or Pregabalin Diazapam in small doses for muscle spasm

Physical Therapy Refer early to Physiotherapy/Osteopath/Chiropractor Monitor progress If not improving at 6 weeks consider a referral to a spinal surgeon for consideration for an epidural injection/nerve root block- gives almost instant relief of pain for 6-12 weeks

Indications for referral and surgery Suspected Cauda Equina syndrome and progressive neurodeficit Diagnosis uncertain Pain not settling by 6-8 weeks Pain severe, disabling and not responding to analgesia Patient who needs to return to work quickly and cannot afford to wait