Lumbar radiculopathy

Definition

Lumbar Radiculopathy (often termed Sciatica) describes radiating leg pain within the distribution of a lumbosacral nerve root, and includes clinical signs of reduced nerve function in the corresponding root level, including sensory changes, reduced power, and/or reduced reflexes.

Typical signs & symptoms

Unilateral leg pain radiating below the knee to the foot or toes
Low back pain – if present, which is less severe than any leg pain
Numbness, tingling in the distribution of a nerve root
Weakness or reflex changes, or both in a myotomal distribution
A positive straight leg raise test

Neurological examination of the legs is either normal or in keeping with a single root lower motor neuron presentation (eg loss of reflexes, sensation and power). Any signs of hyperreflexia, or multilevel lower motor neuron presentation, should prompt a consideration for a different diagnosis. It is important to assess for hip and vascular compromise to allow differential diagnosis.

Prevalence & risk factors

Studies report widely varying estimates of the prevalence of sciatica. Lifetime prevalence is considered to be 13–40%.

Modifiable risk factors which may be associated with the first onset include:

Smoking
Obesity
Occupational factors – for example, whole body vibration, strenuous physical activity
General health

Other risk factors include older age and genetic influences.

Prognosis

Episodes of sciatica are usually transient, with rapid improvements in pain and disability seen within a few weeks to a few months.
Half of people recover spontaneously within 6 weeks.
Reoccurrence of symptoms is common.

Factors associated with a poorer prognosis:

Workplace factors – time off work, problems or dissatisfaction at work, heavy work, or working unsociable hours
Psychological factors – low or negative moods, stress; overprotective family, lack of support, and social withdrawal, the belief that pain and activities are harmful, belief that the problem will last a long time, and inappropriate expectations of treatment

Other considerations

Differential diagnosis:

Neurological disorders – including myelopathy, peripheral neuropathy, neurogenic claudication
Hip OA, greater trochanteric pain syndrome, or other musculoskeletal pain presentation
Vascular Claudication
Non-musculoskeletal causes of back/leg pain

Who can refer:

All primary care clinicians i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners
Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP Where To Find Us – Musculoskeletal Physiotherapy)
Secondary care consultants and associated teams
MSK physiotherapists are able to escalate/refer to spinal advanced practice physiotherapists underpinned by agreed pathways and processes NHS Lothian Integrated Spinal Service

Who to refer:

All routine cases of low back pain and spine related leg symptoms who have not responded to initial primary care management within a 4-6 week period and do not have the presence of significant red flags nor have suspected inflammatory spinal pain – see sections serious lumbar spine conditions and other considerations and inflammatory spinal pain
Spine related leg symptoms- Consider earlier referral in cases intractable symptoms and/ or developing motor deficit but without significant red flags and suspected neurogenic claudication in which symptoms are beginning to affect quality of life and the ability of the patient to look after themselves.
Non-specific low back pain in the absence of a dominant psychological component who have not received recent physiotherapy for their condition or who have received physiotherapy previously for their condition but;

have experienced a substantial change in their presentation
require assistance with achieving a functional goal
wish further assessment and considerations of management options
have clinical features suggestive of an underlying specific cause for their lower back pain i.e. spondylolisthesis, spondylolysis, in which further investigation would guide management (other than serious spinal pathology).For further support & guidance and refer to: Spine pathways | Right Decisions (scot.nhs.uk)

MRI scan is not required at point of referral. If a MRI is indicated as part of a patients management this will be requested within the multi-disciplinary service at the appropriate time for the patient and any intervention that may be required. A patient leaflet to support this decision has been created in conjunction with Neurosurgery, Neurology, Radiology, GPs and Physiotherapy within NHS Lothian available below.
Lumbar x ray is not indicated in patients with spinal related leg symptoms with no adverse features
Additional information regarding imaging available for xray and MRI found at radiology ref help spine Plain X-Rays – RefHelp and neuroradiology ref help Neuroradiology – RefHelp

Who not to refer:

Patients who have the presence of significant red flags/ suspicion of serious lumbar spine condition or have suspected inflammatory spinal pain – see Serious lumbar spine conditions (Red Flags) – RefHelp
Age <16
Chronic back pain with a significant psychological / psychiatric / drug addiction element/ pain causing significant distress & disability, no planned referral to another speciality for diagnosis or treatment of pain – see Chronic pain Chronic Pain – RefHelp.

How to refer:

For all cases of routine low back pain / spine related leg pain – refer via SCI Gateway Referral “AHP-Physiotherapy” then choose local site.
This single referral will gain access to the full multidisciplinary NHS Lothian integrated back pain pathway. Any subsequent investigation/ surgical opinion/ pain service referral will be made within the service
Please include all relevant details on your referral to allow the appropriate initial triage of the patient. Initial triage will occur within MSK Physiotherapy and if appropriate will be passed to spinal advanced practice physiotherapy service.
Please signpost patients to Integrated Spinal Service Webpage for patient information.

Other information

For all routine cases of low back pain and spine related leg pain who meet the criteria under “who to refer”, referral to other specialities including Orthopaedics, Neurosurgery, Neurology & Rheumatology is not indicated. Once within the service patients will be able to access all the multidisciplinary services that are required for their problem including physiotherapy, investigation, surgical opinion and pain clinic opinion. There will be no need for patients to return to their GP to seek additional referrals or investigations for the lumbar spine problem. The service is underpinned by agreed pathways, escalation criteria and multidisciplinary clinics.

Chronic Pain Service

Consider direct referral to Chronic Pain services under the following circumstances:

Patients with chronic low back pain whom;
- do not meet criteria for SCI Gateway Physiotherapy referral as above
- pain causing significant distress and disability
- duration > 6 months
- Age 16 years or over
- No planned referral to another speciality for diagnosis or treatment of pain.

See Chronic Pain RefHelp Page for further information and details

Non specific low back pain and spine related leg symptoms – For further information see associated sections

Key information

Advise the person to seek urgent medical review if there are red flag symptoms or signs suggesting a potentially serious underlying cause.

Provide advice on information and support – for example: NHS Lothian MSK Self-help information webpage

Offer reassurance and advice on self-management strategies

Provide information and advice on the natural history of back pain & spine related leg symptoms to encourage realistic expectations.

Reassure that acute non-specific low back pain is unlikely to have a serious structural cause, and most people recover within weeks.

Sciatica symptoms usually settle within a few weeks to a few months, but in some people they may persist for longer and recurrence is common.

Encourage the person to keep active, resume normal activities, and return to work/study as soon as possible.

Discourage prolonged bed rest. Reassure that normal back movements may produce some pain, but this is not harmful if activities are resumed gradually. Advise there is no need to be pain-free before resuming normal activities.

Consider the short-term application of local heat (such as a heat pack).

Advise to keep as active as possible and exercise regularly to reduce the risk of recurrent episodes.

Optimise medication, if needed – see NICE Guideline NG59 for specific recommendations

Provide information on when they should seek follow up and when to seek immediate medical attention