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Sciatica | NHS inform

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

*Main source of information NICE Sciatica CKS & NICE Guidelines - LBP and Sciatica

Patient resources

Sciatica | NHS inform

Definition

Radicular leg pain (often termed Sciatica) describes radiating leg pain within the distribution of a lumbosacral nerve roots, without any clinical signs of reduced nerve function.

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
• A positive straight leg raise test.

Neurological examination of the legs is expected to be normal. If there are signs of loss of nerve function in keeping with the corresponding nerve root level to the pain distribution, consider Lumbar Radiculopathy as the clinical diagnosis. It is important to assess for hip and vascular compromise to allow differential diagnosis.

Prevalence and risk factors

Studies report widely varying estimates of the prevalence of sciatica. Lifetime prevalence 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.
• Reoccurence 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 withdrawl, the belief that pain and activities are harmful, belieft that the problem will last a long time, and inappropriate expectations of treatment.

Other considerations

Differential diagnosis:

• Hip OA, greater trochanteric pain syndrome, or other MSK pain presentation
• Vascular Claudication
• Non-musculoskeletal causes of back/leg pain

*Main source of information NICE Sciatica CKS & NICE Guidelines - LBP and Sciatica.

Patient resources

NHS Inform – Lumbar Stenosis Lumbar stenosis | NHS inform

Definition

Lumbar spinal stenosis (LSS) refers to age-related degenerative narrowing of the spinal canals that often lead to compression and ischemia of the spinal nerves. The clinical syndrome of LSS is known as neurogenic claudication.

Typical signs & symptoms

Neurogenic claudication is characterised by bilateral or unilateral buttock, lower extremity pain, heaviness, numbness, tingling, or weakness. These symptoms are typically aggravated by walking and standing and relieved by bending forwards such as pushing a trolley, sitting, or lying down. Moreover, patients with lumbar stenosis can also have back pain. However, low back pain with no leg symptoms is usually not thought to be caused by stenosis.

During clinical examination patient often walk with a stooped / flexed posture. They may have pain and stiffness into lumbar spine extension movement. Depending on the severity of the presentation, neurological examination of the legs is either normal or in keeping with a lower motor neurone presentation (eg loss of reflexes, sensation and power). Any signs of hyperreflexia should prompt a consideration for a different diagnosis. Straight leg raise is often negative in patients with neurogenic claudication. It is important to assess for hip and vascular compromise to allow differential diagnosis.

Prevalence and risk factors

LSS is a long-term condition, and symptoms are often variable from day to day.  Studies suggest that those with LSS have greater walking limitations than individuals with knee or hip osteoarthritis and greater functional limitations than those with congestive heart failure and chronic obstructive lung disease (COPD). Inability to walk among individuals with neurogenic claudication leads to sedentary lifestyle and a progressive decline in health status.

Prognosis

The natural history of LSS can be uncertain. Evidence suggests about approximately 1 in 5 people will improve, 3 in 5 people will stay the same, and 1 in 5 people will worsen with time.

Other considerations

Differential diagnosis

LSS is a clinical diagnosis based on history, symptoms, and physical examination. It is important to note that not all leg pain is associated with LSS so consider the pattern of symptoms and the neurological examination. Any hyperreflexia should raise a concern for a differential diagnosis.

Common differential diagnoses include:

• Vascular claudication
• Hip OA, or other musculoskeletal pain presentation
• Degenerative cervical myelopathy, or other neurological presentation.

Patient resources

For reliable, trustworthy patient advice and information direct patients to:

• NHS Inform - Back Problems Information
• NHS Inform - Exercises for back pain
• NHS Lothian MSK Self Help Resources Webpage

Definition

Non-specific radiating leg pain. Pain referred into the leg from the lumbar spine that is not related to irritation or compression of the nerve root.

Typical signs and symptoms

• Typically characterised by dull, aching, gnawing and pressure.
• Its distribution is perceived at a location other than the site of the noxious stimulation.
• It covers a wide area, is difficult to localise, and non-dermatomal.
• It can be in the gluteal area, thigh, occasionally the lower leg but rarely the foot. Usually felt deep and rarely cutaneous.

Differential Diagnosis

• Lumbar radiculopathy
• Radicular leg pain
• Hip OA, greater trochanteric pain syndrome, or other MSK pain presentation
• Non-musculoskeletal causes of back/leg pain

*As the management of non-specific radiating leg pain is closely related to non-specific back pain the above patient information is the same as the non-specific back pain information links