First 5 minutes and stabilization
›Critical pathway activation
›Escalate if cauda equina features present
›Escalate if progressive motor deficit present
›Escalate if sepsis physiology present
›Monitoring and access
›Continuous monitoring for unstable vitals
›IV access for severe pain needing parenteral therapy
›Time sensitive diagnostics
›MRI urgent for suspected cauda equina local protocol dependent
›MRI urgent for suspected epidural abscess local protocol dependent
Analgesia and symptom control
›Non opioid first line options
›Ibuprofen
›400 mg PO every 6 hours as needed
›Maximum 2400 mg per day
›Naproxen
›500 mg PO once
›Then 250 mg PO every 6 to 8 hours as needed
›Maximum 1000 mg per day
›Acetaminophen
›650 mg PO every 6 hours as needed
›Maximum 3000 mg per day
›Neuropathic pain agents local protocol dependent
›Gabapentin not routine first line for acute sciatica local protocol dependent
›Pregabalin not routine first line for acute sciatica local protocol dependent
›Muscle relaxants for short course local protocol dependent
›Cyclobenzaprine
›5 mg PO three times daily as needed
›Maximum 10 mg PO three times daily
›Sedation cautions
›Driving restriction
›Fall risk in older adults
›Opioids local protocol dependent
›Short course only for severe refractory pain after non opioid therapy
›Avoid co prescription with benzodiazepines when possible
›Corticosteroids local protocol dependent
›Oral steroids may provide small functional benefit in disc herniation radiculopathy local protocol dependent
›Avoid in suspected infection
›Avoid in uncontrolled diabetes when possible
Activity and rehabilitation
›Activity guidance
›Relative activity as tolerated
›Avoid prolonged bed rest
›Physical therapy referral local protocol dependent
›Core and hip strengthening focus
›Neural mobilization when appropriate
›Work and ergonomics local protocol dependent
›Modified duties
›Lifting restrictions
›Spine surgery or neurosurgery consult
›Cauda equina features
›Progressive motor deficit
›Epidural abscess concern
›Epidural hematoma concern
›Interventional pain referral local protocol dependent
›Epidural steroid injection for persistent severe radicular pain
›Imaging correlation required prior to injection
›Interval reassessment
›Pain response within 30 to 60 minutes after therapy
›Repeat focused neuro exam after analgesia
›Recheck gait safety before discharge
›Escalation on change
›New weakness triggers urgent imaging pathway
›New urinary retention triggers urgent imaging pathway
›New fever triggers infection pathway