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What is sciatica? Reviews and the NICE guideline
Koes, van Tulder and Peul (BMJ, 2007) describe sciatica as radiating pain in the leg. They write that in about 90% of cases of sciatica the cause is a herniated disc with nerve root compression, and that lumbar stenoses and, less often, tumours are other possible causes. For people with acute sciatica, Koes, van Tulder and Peul (BMJ, 2007) write that most have a favourable prognosis, but about 20% to 30% have persisting problems after one or two years. They also report that CT or MRI shows disc herniation in 20% to 36% of people without symptoms who do not have sciatica.
Sciatica is radiating leg pain. Koes, van Tulder and Peul (BMJ, 2007) call radiating leg pain and related disabilities the most important symptoms. A herniated disc with nerve root compression causes about 90% of cases of sciatica, and lumbar stenoses and, less often, tumours are other possible causes.
NG59 (30 November 2016, last updated 29 July 2026) covers low back pain and sciatica in people aged 16 and over. I had low back pain for about ten years and have no medical or physical-therapy credentials.
What the research and guidelines found
WHO's 7 December 2023 release defines chronic primary low back pain as pain lasting more than 3 months that is not due to an underlying disease or other condition. For adults with chronic primary low back pain, WHO recommends education programs that support knowledge and self-care strategies, exercise programs, some physical therapies such as spinal manipulative therapy and massage, psychological therapies such as cognitive behavioural therapy, and medicines such as non-steroidal anti-inflammatory medicines. The release names 14 interventions that should not be routinely offered for most adults with chronic primary low back pain in most contexts, because potential harms likely outweigh the benefits, such as lumbar braces, traction, and opioid pain killers.
| Source | Finding | Evidence |
|---|---|---|
| Konstantinou and Dunn, 2008 | In 23 studies, sciatica prevalence ranged from 1.2% to 43%. | Only 2 of 23 used clinical assessment. Definitions varied widely. |
| Dahm and colleagues, 2010 | In this review of advice for acute low back pain and sciatica, for people with sciatica there is moderate quality evidence of little or no difference in pain relief or functional status between advice to rest in bed or stay active. | Moderate quality. |
| Dahm and colleagues, 2010 | In the same review, low quality evidence from 1 trial of 250 people suggests little or no difference between physiotherapy, advice to rest in bed or stay active for people with sciatica. | Low quality. |
| Koes, van Tulder and Peul, 2007 | In the randomised SPORT trial, 501 people had sciatica for at least six weeks and confirmed disc herniation. Both treatment groups improved substantially over two years. Small differences favoured surgery but were not statistically significant for the primary outcome measures. Separately, the review concludes that disc surgery may provide quicker relief of leg pain than conservative care, but no clear differences have been found after one or two years. | Within three months, 50% randomised to surgery and 30% randomised to conservative care had surgery. By two years, 60% of the surgery group and 45% of the conservative group had surgery. |
For people aged 16 and over with sciatica, NG59 (2020) says not to offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines, because there is no overall evidence of benefit and there is evidence of harm. The guideline says not to offer opioids for chronic sciatica (3 months or longer) and to be aware of the risk of harms and limited evidence of benefit from non-steroidal anti-inflammatory drugs in sciatica.
What to do in practice
- NG59 says to provide people aged 16 and over with low back pain, with or without sciatica, advice and information that includes encouragement to continue with normal activities. It also says to promote and facilitate return to work or normal activities of daily living.
- In a non-specialist setting, NG59 says not to routinely offer imaging for people aged 16 and over with low back pain, with or without sciatica.
- Koes, van Tulder and Peul (BMJ, 2007) say imaging in sciatica is indicated only for red-flag conditions or when disc surgery is considered. When surgery is considered, they say it is important that the clinical findings and symptoms correspond well with the scan findings.
- For people aged 16 and over with a specific episode or flare-up of low back pain, with or without sciatica, NG59 says to consider a group exercise programme within the NHS.
- For people with sciatica, Koes, van Tulder and Peul (BMJ, 2007) say consensus is that initial treatment is conservative for about 6 to 8 weeks.
- Koes, van Tulder and Peul (BMJ, 2007) say consensus is that cauda equina syndrome is an absolute indication for immediate surgery.
- NG59 says to consider epidural injections of local anaesthetic and steroid for people aged 16 and over with acute and severe sciatica (less than 3 months).
- When non-surgical treatment has not improved pain or function and radiological findings are consistent with sciatic symptoms, NG59 says to consider spinal decompression for people aged 16 and over with sciatica.
Where the program in the app fits
Low Back Pain Coach requires a 45-degree back-extension bench. Floor Foundations is floor work with no equipment. It lasts only until you have a bench. It is not an equipment-free version of the program. The program is not written for a vertical 90-degree Roman chair. Recent workouts and pain logs set each session. The first guided session is free. Later guided sessions require a plan. If pain is in your legs, or it spreads that way during the movement, or you log leg pain, stop the extension work for your back and do not add load. This exact bench progression has not been tested in a trial.
When to get care
Go to emergency care now for any of these:
- New numbness, tingling or change in feeling in the saddle area: around the groin, inner thighs, genitals or anus, or when you wipe
- New trouble getting or keeping an erection, not being able to orgasm, or a change in feeling during sex
- New bladder or bowel changes: trouble starting or stopping pee, a weak stream, not feeling when you need to go, or leaking pee or poo
- New pain, tingling, numbness or weakness in both legs
- Leg or foot weakness that is getting worse (tripping, a foot that slaps down)
- Back pain that started after a recent serious accident, like a car crash or a bad fall
See a clinician today (urgent care if no appointment today) for any of these:
- Other new weakness or numbness in one leg or foot
- Fever or chills alongside the back pain
- New pain after a recent smaller fall or knock
- Unexplained weight loss, or a history of cancer
- Pain that is rapidly getting worse
- Pain that is constant at rest and worse at night, not tied to movement
Common questions
What is sciatica?
Koes, van Tulder and Peul (BMJ, 2007) write that the most important symptoms are radiating leg pain and related disabilities. In about 90% of cases of sciatica, a herniated disc with nerve root compression is the cause, and lumbar stenoses and, less often, tumours are other possible causes.
How is sciatica different from low back pain?
Konstantinou and Dunn (Spine, 2008) describe sciatica as more persistent and severe than low back pain, with a less favorable outcome.
How long do sciatica problems last?
Koes, van Tulder and Peul (BMJ, 2007) write that most people with acute sciatica have a favourable prognosis, but about 20% to 30% have persisting problems after one or two years.
What does NICE say about gabapentin and similar drugs for sciatica?
For people aged 16 and over with sciatica, NG59 (2020) says not to offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines, because there is no overall evidence of benefit and there is evidence of harm. The guideline says to explain the risks of continuing opioids, gabapentinoids or benzodiazepines already taken for sciatica.
What usually happens with a new episode of low back pain?
Hartvigsen and colleagues (Lancet, 2018) report that most people with a new episode of low back pain recover quickly, but recurrence is common, and in a small proportion of people low back pain becomes persistent and disabling.
When should I stop and see a doctor?
Go to emergency care now for any of these: New numbness, tingling or change in feeling in the saddle area: around the groin, inner thighs, genitals or anus, or when you wipe; New trouble getting or keeping an erection, not being able to orgasm, or a change in feeling during sex; New bladder or bowel changes: trouble starting or stopping pee, a weak stream, not feeling when you need to go, or leaking pee or poo; New pain, tingling, numbness or weakness in both legs; Leg or foot weakness that is getting worse (tripping, a foot that slaps down); Back pain that started after a recent serious accident, like a car crash or a bad fall. See a clinician today (urgent care if no appointment today) for any of these: Other new weakness or numbness in one leg or foot; Fever or chills alongside the back pain; New pain after a recent smaller fall or knock; Unexplained weight loss, or a history of cancer; Pain that is rapidly getting worse; Pain that is constant at rest and worse at night, not tied to movement.
Sources
- Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ. 2007;334(7607):1313-1317. doi:10.1136/bmj.39223.428495.BE. PMID: 17585160. link
- Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976). 2008;33(22):2464-2472. doi:10.1097/BRS.0b013e318183a4a2. PMID: 18923325. link
- Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;2010(6):CD007612. doi:10.1002/14651858.CD007612.pub2. PMID: 20556780. link
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59. Published 30 November 2016. Last updated 29 July 2026. Recommendations chapter. link
- Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X. PMID: 29573870. link
- World Health Organization. WHO releases guidelines on chronic low back pain. Departmental update, 7 December 2023. link
The app
Low Back Pain Coach runs a guided strength program on a 45-degree back-extension bench: floor work until you have a bench, then four stages from short holds to weighted reps. You log your pain the next morning, and that log sets the next session. A voice counts the holds, reps and rest.
Your first guided session is free. Then $59.99 a year or $9.99 a month, renewing until you cancel, with a 7-day free trial for eligible new subscribers. US prices. iPhone and Android. The 45-degree bench is required. What the app does.
The program on one page
The printable program card has the four stages, the next-morning rule, and the stop signs on one sheet.
If you want an email when the program or the app changes, leave your address. A few emails a year at most, and a reply to any of them takes you off the list.