Low Back Pain & Radiculopathy

Non-specific LBP presents as lumbosacral pain that may refer to buttock or posterior thigh but does not radiate below the knee in a dermatomal pattern and lacks neurological symptoms. Pain is usually mechanical, postural or activity-related.

Radicular pain (sciatica) is dermatomal leg pain typically worse than back pain, often sharp, shooting, burning, or electric in quality. Pain provoked by coughing, sneezing, or straining suggests disc herniation (raised intrathecal pressure). Numbness, weakness, or paraesthesia signal radiculopathy.

Neurogenic claudication suggests spinal stenosis: bilateral or unilateral leg pain or heaviness brought on by walking or prolonged standing, relieved by sitting or spinal flexion. The shopping-trolley sign - improved walking distance when leaning forward - is classic. Distinguish from vascular claudication, which is provoked by walking alone (not standing) and relieved by simple rest with normal peripheral pulses.

Examination: posture, gait and lateral shift; lumbar range of movement; SLR (positive if dermatomal leg pain reproduced below the knee at under 60 degrees, high sensitivity, moderate specificity); crossed SLR (less sensitive but more specific for disc herniation); femoral stretch test for upper lumbar roots.

Neurological screen by myotome, dermatome, reflex:

• •L2: hip flexion
• •L3: knee extension
• •L4: ankle dorsiflexion and inversion, knee jerk
• •L5: great toe extension (EHL) and hip abduction (gluteus medius)
• •S1: plantarflexion and eversion, ankle jerk

L5 hip-abduction weakness distinguishes L5 radiculopathy from common peroneal nerve palsy - both cause foot drop. Assess perianal sensation and anal tone if cauda equina is suspected.

Differentials: facet joint pain (extension and rotation-provoked, no dermatomal symptoms), SIJ dysfunction, spondylolisthesis, inflammatory spondyloarthropathy (young patient, insidious onset, morning stiffness over 30 minutes improving with exercise), hip OA (groin pain, restricted internal rotation), and visceral or vascular pathology.

NICE NG59 is explicit: do not routinely image LBP. MRI changes (disc bulge, protrusion, degeneration) are present in a large proportion of pain-free adults, and imaging without clear indication drives anxiety, medicalisation, and unnecessary intervention.

Image when:

• •Cauda equina syndrome is suspected: immediate MRI
• •Red flags suggest malignancy or infection: urgent MRI
• •Spinal injection or surgery is being considered

Plain radiographs have a limited role but may help when fracture, spondylolisthesis, or inflammatory spondyloarthropathy is suspected. Bloods (FBC, ESR, CRP) are warranted when infection, malignancy, or inflammatory spondyloarthropathy is on the differential. Validated outcome measures: STarT Back Screening Tool, Roland-Morris Disability Questionnaire, Oswestry Disability Index.

NICE NG59 (Low back pain and sciatica in over-16s, 2016, updated 2020) is the central UK document. Stratify risk early with STarT Back: lower-risk patients receive brief advice and supported self-management; higher-risk patients receive a combined physical and psychological programme.

NICE stepped care: red flag screen, supported self-management with reassurance and education, structured group exercise (biomechanical, aerobic, mind-body, or combination), psychological therapy where psychosocial factors dominate, and imaging only when intervention is being considered.

Reassurance and active management are universal. Most episodes improve over weeks. Bed rest is harmful. Graded return to normal activities reduces chronicity.

Pharmacological (NG59):

• •Oral NSAIDs at the lowest effective dose for the shortest period with gastroprotection
• •Weak opioids (with or without paracetamol) only for acute LBP if NSAIDs are contraindicated, not tolerated, or ineffective
• •Do not offer paracetamol alone, opioids for chronic LBP, antidepressants for LBP, or gabapentinoids and antiepileptics for LBP
• •Do not offer gabapentinoids, antiepileptics, oral corticosteroids, or benzodiazepines for sciatica

Treatments NOT recommended by NG59: acupuncture, TENS, PENS, ultrasound, interferential therapy, traction, orthotics, belts or corsets, rocker-sole shoes.

Invasive treatments:

• •Epidural local anaesthetic and steroid: consider for acute severe sciatica. Short-term symptom relief. Does not alter natural history. Not for stenosis-related neurogenic claudication
• •Radiofrequency denervation: consider for chronic localised LBP after a positive diagnostic medial branch block, when conservative treatment has failed
• •Spinal decompression: consider for sciatica when conservative measures have failed and imaging matches symptoms. Do not exclude based on BMI, smoking, or psychological distress
• •Spinal fusion: do not offer for non-specific LBP

Cauda equina syndrome is a surgical emergency: immediate MRI and emergency spinal surgery referral. Do not delay.

Acute phase: reassurance, early activity, graded return. Bed rest is harmful.

Exercise: per NG59, type matters less than consistency. Group programmes combining biomechanical, aerobic, and mind-body elements are first-line. Tailor intensity to STarT Back risk - brief advice for lower-risk, combined physical and psychological programmes for higher-risk.

Return to work: support early, graduated return with workplace modifications. Prolonged absence worsens prognosis. Address blue flags (workplace perceptions) and black flags (workplace barriers) proactively.

Radiculopathy: progressive exercise as symptoms allow. Symptom-guided neural mobilisation (gliding and sliding). Core stability and general aerobic fitness.

Post-surgical: after microdiscectomy, early mobilisation with sedentary return at 2-4 weeks and manual work at 6-12 weeks. After decompression, gradual return to walking tolerance.

Yellow flags - fear-avoidance, catastrophising, low mood - are the strongest predictors of chronicity. Address them in every plan.

• •NICE NG59 (2016, updated 2020): Stratified care for LBP and sciatica with NSAIDs first-line, structured exercise, and judicious imaging. Lists treatments specifically not recommended.
• •STarT Back trial (Hill et al., Lancet 2011): Stratified primary-care management using the STarT Back tool reduced disability and was cost-effective compared to current best practice.
• •Boden et al. (NEJM 1990): Lumbar MRI abnormalities are common in asymptomatic adults - underpins the NG59 message that imaging alone does not equate to clinical diagnosis.
• •SPORT trial (Weinstein et al., JAMA 2006): Discectomy provided earlier symptomatic relief than non-surgical care in lumbar disc herniation but long-term outcomes converged. Informs surgical timing decisions.
• •BASS / SBNS Cauda Equina UK guideline (2018): Immediate MRI and emergency spinal surgery referral when CES is suspected.
• •NICE CKS Sciatica and Low back pain: primary-care implementation aligned to NG59.

• •NICE NG59 do-not-offer list is heavily examined: paracetamol alone, opioids for chronic LBP or sciatica, antidepressants or gabapentinoids for LBP, oral corticosteroids or benzodiazepines for sciatica, acupuncture, TENS, traction, and spinal fusion for non-specific LBP.
• •L5 hip-abduction weakness (gluteus medius) distinguishes L5 radiculopathy from common peroneal nerve palsy - both cause foot drop.
• •Radicular pain is a symptom (dermatomal leg pain); radiculopathy is a sign (motor, sensory, or reflex deficit). Vignettes test the distinction directly.
• •Radiofrequency denervation requires a positive diagnostic medial branch block first - commonly tested NG59 detail.
• •Yellow flags (psychosocial) predict chronicity more strongly than physical findings and drive stratified management.
• •Neurogenic claudication is relieved by spinal flexion (shopping-trolley sign); vascular claudication is relieved by simple rest with normal peripheral pulses.