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Sciatica -Lumbar radiculopathy

Sciatica is a set of symptoms rather than a specific diagnosis and is caused by a herniated lumbar disc in the vast majority of cases.Often applied to any presentation of low back and leg pain Lumbosacral radiculopathy is a more specific term – impingement of lumbosacral nerve roots as they emerge from the spinal canal
 4th and 5th Lumbar nerve roots ( L4-L5 )
First two Sacral (S1 and S2 ).Sciatic nerve- largest nerve in body Disturbance anywhere along the course of the sciatic nerve 
can cause –> Sciatica
○ most common are disc ruptures and osteoarthritis at
L4 – L5
L5 – S1
L3 – L4 – less frequently
 Radiating pain , tingling and numbness – dermatomal distribution
may be accompanying motor weakness in a corresponding myotomal distribution
 Symptoms typically extend 
○ below the knee from buttocks
○ across the back of thigh
○ outer calf
○ often to foot and toes.Acute sciatica
 generally has a 
 good prognosis with pain and disability usually improving within 
2-4 weeks- with or
 without treatment

Back pain accounts 
for 7 % of GP consultations
 and more than 30 % of people still have clinically 
significant symptoms 
after a year after onset of sciatica .Causes- Herniated intervertebral disc ( slipped disc ) with nerve root compression 90 % of cases Lumbar stenoses Spondylolisthesis – a proximal vertebra moves forward relative to a distal vertebra Infection ( rare ) Cancer ( rare ) – often due to metastatic disease Genetic factors ( could have a role in disc degeneration and herniation ).Asymptomatic disc
 herniation on CT/MRI are 
common and there is no
 clear relationship between
 the extent of disc protrusion 
and the degree of clinical 

Mainly diagnosed by history and clinical examination Usually unilateral
B/L pain may happen with 
♦ central disc herniation
♦ lumbar stenosis
♦ spondylolisthesis Drawings may be used to evaluate the distribution Increased back and sciatic pain with coughing , sneezing , straining or other forms of Valsalva maneuver may suggest disc rupture
 S1 compression –> reduction or loss of ankle reflex
L3-L4 compression –> variable reduction in knee reflex
L5 compression –> inconsistent changes in reflexes
 Straight leg raise test – Lasègue’s test
Positive test –> reproduction or marked worsening of the patients initial pain and firm resistance to further elevation of leg Sensitivity 90 % but specificity low. Cross straight- leg-raising -test 
( Fajersztajn’s test ) involves raising the unaffected leg

Red flags- Cauda equina syndrome
 Spinal fracture
as discitis , vertebral osteomyelits or 
spinal epidural abscess

Differential diagnosis- Osteoarthritis- referred pain from hip Spondyloarthopathies – eg sacroillitis in ankylosing spondylitis Intervertebral facet joint pain Trochanteric bursitis Piriformis syndrome Peroneal palsy or other neuropathies Spina claudication Aseptic necrosis of femoral head Myelopathy or a higher cord lesion Non specific causes as
○ prostatitis
○ Pelvic mass
○ Aortic aneurysm
○ Pancreatitis
○ Acute cholecytitis

Unilateral leg pain greater than low back pain Pain radiating to foot or toes Numbness and paraesthesia in the same distribution SLR induces more leg pain Localised neurology – that is limited to one nerve root.Do not routinely offer imaging in a non-specialist setting for people with LBP with or without sciatica ( NICE )
 X ray not routinely recommended – discs cannot be seen on XR

During 1 yr f/u irrespective of a surgical or conservative management- MRI findings seem not helpful in determining which patients might fair better with early surgery compared with a strategy of prolonged conservative management 
( J Neurosurg Spine Jun 2016 )

Referral for further care- Red flag symptoms and signs- admit / refer urgently as appropriate Consider referral to Physiotherapy for
○ manual therapy – spinal manipulation , mobilisation or massage as part of a treatment package including exercise Progressive persistent or severe neurological deficit ( Neurosurgery or T/ O ) Consider referral to specialist LBP & sciatica service for assessment of an epidural corticosteroid / local anaesthetic injection Consider referral for spinal decompression when non surgical treatment has not improved pain or function NICE also recommends referral to rediofrequency denervation if conservative treatment nor worked – main source of pain from structures supplied by medial branch nerve and pain is rated 5 or more on a visual analogie scale

management- NSAIDs- carry out risk assessment + gastroprotection for short term relief Weak opioids ( with or without paracetamol) only if NSAID is contraindicated , not tolerated or has been ineffective Do not offer weak opioids for managing chronic lower back pain Do not offer paracetamol alone Anti-epileptics
Pregabalin – poor evidence ( NEJM 2017 ) does not decrease pain
Gabapentin – has shown greater efficacy in pain reduction compared to placebo



NHS on sciatica

Printable 2 page leaflet- auto-download from Mid Essex Hospital Services

36 page booklet from Arthritis Research on back pain

2 page printable leaflet from Pain relief foundation Org

Exercises for sciatica from NHS

Keele University leaflet for back pain endorsed by NICE

Simple back pain exercises leaflet from CSP Org ( Arthritis research )

Information from Health share Oxfordshire org with a helpful video

Neuropathic pain 8 page printable leaflet from Painconcern org -an excellent resource

Fit for work advice on sciatica


Low back pain and sciatica in over 16s : assessment and management NG 59

Chartered Society of Physiotherapy Clinical update: low back pain and sciatica Neil O’Connell examines the clinical guideline on low back pain and sciatica, which was recently updated by NICE

Keele STarT Back Screening Tool

Startback website

SIGN management of chronic pain

Europe PMC Diagnosis and treatment of sciatica

A good read Clinical practice guidelines for the management of non-specific low back pain in primary care : an updated overview Oliveira, C.B., Maher, C.G., Pinto, R.Z. et al. Eur Spine J (2018) 27: 2791. 


  1. Diagnosis and treatment of sciatica BMJ 2007 ; 334 :1313
  2. Sciatica N Engl J Med 2015 ; 372-1240-1248 ( March 26 , 2015 )
  3. A Summary of the Guideline for the Evidence-Informed Primary Care Management of Low Back Pain
  4. Low back pain and sciatica in over 16s : assessment and management NICE guideline NG59 November 2016
  5. Jordan, Joanne L et al. “Herniated lumbar disc: injection interventions for sciatica.” BMJ Clinical Evidence vol. 2016 1118. 9 Feb. 2016
  6. CKS Sciatica ( Lumbar radiculopathy ) via
  7. Chou R, Qaseem A, Snow V, et al, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491. doi:
  8. Sciatica from disk herniation : Medical treatment or surgery Erick Legrand et al Joint Bone Spine , 2007-12-01 , volume 74 , Issue 6 , Pages 530-535
  9. Pregabalin and gabapentin for the treatment of sciatica Kellvin Robertson et al Journal of Clinical Neuroscience , 2016-04-01 , Volume 26 , Pages 1-7
  10. Low Back Pain and Sciatica Anthony H Wheeler et al Medscape February 2016
  11. Treating sciatica in the face of poor evidence BMJ 2012 ;344:e487
  12. Low back pain and sciatica : summary of NICE guidance BMJ 2017 ;356 :i6748
  13. Drugs for relief of pain in patients with sciatica : systemic review and meta-analysis BMJ 2012 ; 344 :e497
  14. Trial of Pregabalin for Acute and Chronic Sciatica N Engl J Med . 2017 Mar 23 ; 376 (12) : 1111-1120 ( Abstract )
  15. BodyinMind.Org ; Pregabalin for sciatica increasing prescription but is it effective ?
  16. Sciatica :what the rheumatologist needs to know Maurits van Tulder et al.  2010 Mar;6(3):139-45. doi: 10.1038/nrrheum.2010.3. Epub 2010 Feb 9.
  17. Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2020 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
  18. Jensen Rikke KKongsted AliceKjaer PerKoes BartDiagnosis and treatment of sciatica 
  19. Valat JP, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best Practice & research. Clinical Rheumatology. 2010 Apr;24(2):241-252. DOI: 10.1016/j.berh.2009.11.005. ( Abstract )
  20. Lewis R, Williams N, Matar HE, et al. The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model. Southampton (UK): NIHR Journals Library; 2011 Nov. (Health Technology Assessment, No. 15.39.) 3, Background. Available from:

















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