How should I approach the management of chronic sciatica in a patient who has not responded to conservative treatment?

Management of chronic sciatica in a patient unresponsive to conservative treatment should include:

• Consider referral for a combined physical and psychological programme incorporating a cognitive behavioural approach, preferably in a group context tailored to the person's needs and capabilities, especially if psychosocial obstacles to recovery exist or previous treatments have failed.
• Arrange specialist referral if pain is severe or non-tolerable after 6 weeks, or if function has not improved with non-surgical treatment.
• Consider spinal decompression surgery if radiological findings are consistent with sciatic symptoms and non-surgical treatments have not improved pain or function.
• Epidural corticosteroid injections may be considered for acute and severe sciatica but have only small short-term benefits and are less commonly used in chronic cases.
• Do not offer gabapentinoids, opioids, oral corticosteroids, benzodiazepines, or antidepressants for chronic sciatica due to lack of evidence of benefit and potential harm.
• Continue to promote and facilitate return to normal activities and work, and consider group exercise programmes and manual therapy only as part of a package including exercise and psychological therapy.
• Avoid imaging unless it will change management, and do not offer treatments such as foot orthotics, belts, corsets, traction, acupuncture, ultrasound, TENS, or PENS.

These steps align with NICE guidelines and related UK recommendations for managing chronic sciatica after failure of conservative treatment.

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