Do I Need a Sciatica Doctor or a Spine Surgeon?
Both can help, but they approach sciatica differently. Pain management doctors excel at injections and medication optimization. Spine surgeons evaluate structural problems and determine if surgery might help. Here's how to decide who to see first, and when to escalate.
Start With Your Primary Care Doctor
For new-onset sciatica without red flags, your primary care physician is often the right first stop. They can:
- Confirm the diagnosis through physical exam
- Rule out other causes of leg pain (vascular, hip problems)
- Prescribe initial medications and activity modifications
- Order physical therapy
- Refer you to a specialist if symptoms persist or worsen
Most sciatica improves within 6-8 weeks with conservative care. If yours does, you may never need a specialist. But if symptoms persist, worsen, or you develop weakness, it's time to escalate.
When to See Pain Management
Pain Management Is Best For:
- Epidural steroid injections — Their primary expertise; can provide significant relief for acute disc herniations
- Medication management — Optimizing nerve pain medications, muscle relaxants, anti-inflammatories
- Multimodal pain control — Combining different approaches to avoid opioid dependence
- Chronic pain management — Long-term strategies when surgery isn't appropriate
Pain management doctors use fluoroscopic guidance to precisely target injections. They're excellent at determining if inflammation is the primary driver of your symptoms. If injections provide significant relief, you may avoid surgery entirely.
When to See a Spine Surgeon
Spine Surgery Consultation Is Best For:
- Structural evaluation — Determining if the problem is mechanical (large disc fragment, stenosis) vs inflammatory
- Progressive weakness — Foot drop or significant leg weakness developing over days to weeks
- Failed conservative care — 8-12 weeks without improvement despite PT, medications, and possibly injections
- Surgical candidacy assessment — Determining if surgery is likely to help your specific situation
- Second opinion — You've been told you need surgery and want another perspective
A spine surgeon evaluates whether the structural problem on your MRI matches your symptoms and whether surgical decompression is likely to help. We also determine if you're a candidate for minimally invasive approaches. Not every patient with sciatica needs surgery, and a good surgeon will tell you when conservative care is still appropriate.
The Collaborative Approach
In many cases, pain management and spine surgery work together. Here's a common pathway:
Initial Conservative Care (0-6 weeks)
Primary care manages with PT, medications, activity modification
Pain Management Referral (6-8 weeks)
If symptoms persist, epidural injections attempted
Spine Surgery Consultation (8-12 weeks)
If injections fail or weakness develops, surgical evaluation
Ongoing Collaboration
Pain management continues medication optimization; surgeon provides structural assessment and surgical option if appropriate
I often work with pain management colleagues. They handle injections while I provide surgical consultation. This team approach ensures you get the right treatment at the right time without unnecessary delays or premature surgery.
What Changes the Plan
Certain situations warrant immediate spine surgery consultation, bypassing the usual stepwise approach:
Go Directly to Spine Surgeon If:
- Bowel or bladder dysfunction develops (cauda equina syndrome—this is urgent)
- Progressive foot drop over days to weeks
- Severe, unrelenting pain despite appropriate medications
- You've already had multiple failed injections
- MRI shows large disc sequestration (free fragment)
What to Expect at Each Visit
Pain Management Visit
- Review of symptoms and prior treatments
- Physical exam focused on pain patterns
- Review of imaging (MRI)
- Discussion of injection options and timing
- Medication adjustments
- Follow-up plan based on response
Spine Surgery Visit
- Detailed history and symptom timeline
- Neurological exam (strength, sensation, reflexes)
- Review of MRI with you—explaining findings
- Discussion of all treatment options (including non-surgical)
- Surgical candidacy assessment
- Realistic expectations about outcomes
My Recommendation
If you're within the first 6-8 weeks of symptoms and have no red flags, start with your primary care doctor or pain management. They can initiate conservative care and injections if appropriate.
If you're beyond 8-12 weeks without improvement, have progressive weakness, or have already failed injections, schedule a spine surgery consultation. We can evaluate whether surgery is likely to help and provide a clear treatment plan.
You don't need to choose one or the other permanently. Many patients benefit from both specialists working together. The key is getting the right evaluation at the right time.
At Greenberg Spine, I provide comprehensive evaluation regardless of where you are in your treatment journey. If conservative care is still appropriate, I'll tell you. If surgery makes sense, we'll discuss all options including minimally invasive approaches.
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