Severe walking intolerance? Conservative care worth a shot?
35M here.
History
At age 19 I once injured my lower back by trying to lift super heavy furniture. Since then I've had sciatica that has been mild / moderate and easily manageable. I mostly only had pain down the right leg and no back pain. About 3 years ago when I first did core exercises religiously for 2 weeks, my sciatica completely disappeared for the first time ever and it was great.
Current state
But about 8 months ago, the latest "flare-up" started which has been very persistent and only gotten a bit worse. I can't walk more than 2-3 mins without the pain really building. I could play pickleball great but as of lately that's been tough too and for the past week sleeping has been painful and I've been sleeping 2 hours less per night even with advil. In general flexion helps but lately I've had this mild to moderate pain sometimes even in flexion, particularly behind my knee or on the outer/back of thigh, so there may be an acute sciatica component or some new nerve irritaiton, idk. The MRI this week vs 6 months ago actually seem to be almost identical, no clear worsening (but symptoms have improved, then lately worsened even more).
MRI
What I tried
Meloxicam didn't do anything. Medrol pack reduced pain a lot but made the numbness much more apparently; I guess I'd call it an overall mild to moderate improvement. ESI might have resulted in partial improvement but not more than 30%. I did PT here and there but honestly didn't do it properly or religiously because of a) pain b) lack of motivation / signal that it'll help and c) possibly aggravated nerve in doing so. Inversion table also seemed to help the very first time I did it for 10 mins but since then I haven't exprienced that improvement and it seems to just aggravate the nerve. In fact in the past 2 weeks or so most things seem to aggravate my nerve very easily, even things that might otherwise help, like inversion table or PT.
What to do next?
I can:
a) Get an ESI again, go see this new PT who's supposed to be more of a spine expert, and give that a month. But honestly my life is miserable right now - extremely limited and eating a lot and inactive and putting on weight. I still go and play pickleball and push through some pain / take breaks / alter my stance etc and can cycle and can workout at the gym with care. But the limitation sucks. If there is a real chance I can get to much better function without surgery (say 15 mins walking tolerance) after a month or max two of PT, I'd treat that as a win. But if it's unlikely, I wouldn't want to waste my time.
b) Get the decompression surgery.
What do you think? Is there a good chance conservative care will help?
tl;dr - 35M, mild sciatica for 15 years, major walking intolerance for 6-8 months, some up and down in symptoms but nothing clearly helped including ESI (didn't do PT very religiously). Is there hope for conservative care? Or should I jump to decompression surgery?
