Musculoskeletal System >
Sciatica (Lumbar Radiculopathy)

“Symptoms of pain, tingling, and numbness which arise from nerve root compression or irritation in the lumbosacral spine”

Risk Factors
  • Increased risk of developing sciatica:
    • Strenuous physical activity, for example, heavy lifting or jogging.
    • Whole-body vibration, for example, driving.
  • Modifiable factors associated with the first onset of sciatica:
    • Smoking
    • Obesity
    • Occupational factors
    • General health
Aetiology
  • A herniated intervertebral disc (90% of cases), Spondylolisthesis, Spinal stenosis.
  • Cancer and infection (rare).
Pathophysiology
  • Sciatic nerve L4-S3 can be damaged by pelvic tumours or fractures to pelvis or femur.
  • Lesions affect the hamstrings and all muscles below the knee (> foot drop), with loss of sensation below the knee laterally
Clinical Presentation
  • Unilateral leg pain radiating below the knee to the foot or toes.
  • Low back pain, numbness, tingling (paraesthesia), and muscle weakness in the distribution of a nerve root (dermatome).
  • Red flags:
    • Cauda equina syndrome
    • Spinal fracture
    • Cancer
    • Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess)
Investigations
  • Positive straight leg raising test, Extensor plantar response
  • XRay of the lumbar spine
  • CT and MRI imaging only to be requested if serious underlying pathology is suspected
Management
  • Admission or urgent referral to a neurosurgeon or orthopaedic surgeon if:
    • Red flag symptoms are present
    • There is a progressive, persistent, or severe neurological deficit
  • Adequate analgesia (an NSAID first-line, or codeine with or without paracetamol if an NSAID is contraindicated or not tolerated).
    • If analgesia is not effective, drugs to treat neuropathic pain can be prescribed.
  • Assess the risk of back pain disability using a risk stratification tool.
    • Offer higher risk patients referral for group exercise, and/or cognitive behavioural therapy, and/or physiotherapy.
  • Consider referral to low back pain specialist referral for an epidural corticosteroid/ local anaesthetic injection.
  • Assessment for radiofrequency denervation, or spinal decompression if non-surgical treatment has not improved pain or function.
  • Provide information about its expected time course, self-help measures, advice about staying active, resuming normal activities, and returning to work as soon as possible.
Complications
  • Permanent nerve damage
  • Psychosocial problems eg Anxiety, depression, and impact on family
  • Loss of employment from time off work, reduced productivity

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