Back Pain and Sciatica

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  • Anatomy
• Low back pain is very common and has many causes
• Lumbago


  Another term for low back pain
• Non-specific or mechanical lower back pain


  Refers to the majority of patients who do not have a specific disease causing their lower back pain
• Sciatica


  Refers to the symptoms associated with irritation of the sciatic nerve
• Acute low back pain should improve within 1-2 weeks. Recovery can take longer (4-6 weeks) for sciatica
• Chronic lower back pain

  Can have a massive impact on the patient’s quality of life and be difficult to manage
• Challenges with managing patients with lower back pain

  • Identifying serious underlying pathology
  • Speeding up recovery
  • Reducing the risk of chronic lower back pain
  • Managing symptoms in chronic lower back pain
• Causes of Mechanical Back Pain

  1. Muscle or ligament sprain

  2. Facet joint dysfunction

  3. Sacroiliac joint dysfunction

  4. Herniated disc

  5. Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)

  6. Scoliosis (curved spine)

  7. Degenerative changes (arthritis) affecting the discs and facet joints
• Causes of Neck Pain

  1. Muscle or ligament strain (e.g., poor posture or repetitive activities)

  2. Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)

  3. Whiplash (typically after a road traffic accident)

  4. Cervical spondylosi
• Causes of Neck Pain

  • Muscle or ligament strain (e.g., poor posture or repetitive activities)
  • Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)
  • Whiplash (typically after a road traffic accident)
  • Cervical spondylosis (degenerative changes to the vertebrae)
• Red-Flag Causes of Back Pain

  • Spinal fracture (e.g., major trauma)
  • Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs)
  • Spinal stenosis (e.g., intermittent neurogenic claudication)
  • Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)
  • Spinal infection (e.g., fever or a history of IV drug use)
• Other Causes of Back Pain

  • Pneumonia
  • Ruptured aortic aneurysms
  • Kidney stones
  • Pyelonephritis
  • Pancreatitis
  • Prostatitis
  • Pelvic inflammatory disease
  • Endometriosis
  • Sciatica
• Sciatica

  Causes unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet. It might be described as an “electric” or “shooting” pain. Other symptoms are paraesthesia (pins and needles), numbness, and motor weakness. Reflexes may be affected depending on the affected nerve root
• Main causes of sciatica

  1. Lumbosacral nerve root compression by: Herniated disc

  2. Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)

  3. Spinal stenosis
• Bilateral sciatica


  Red flag for cauda equina syndrome
• History and Examination

  Use the SOCRATES mnemonic: S – Site O – Onset C – Character R – Radiation A – Associations T – Timing E – Exacerbating and relieving factors S – Severity
• Key symptoms in the history

  • Major trauma (spinal fracture)
  • Stiffness in the morning or with rest (ankylosing spondylitis)
  • Age under 40 (ankylosing spondylitis)
  • Gradual onset of progressive pain (ankylosing spondylitis or cancer)
  • Night pain (ankylosing spondylitis or cancer)
  • Age over 50 (cancer)
  • Weight loss (cancer)
  • Bilateral neurological motor or sensory symptoms (cauda equina)
  • Saddle anaesthesia (cauda equina)
  • Urinary retention or incontinence (cauda equina)
  • Faecal incontinence (cauda equina)
  • History of cancer with potential metastasis (cauda equina or spinal metastases)
  • Fever (spinal infection)
  • IV drug use (spinal infection)
• Key findings on examination

  • Localised tenderness to the spine (spinal fracture or cancer)
  • Bilateral neurological motor or sensory signs (cauda equina)
  • Bladder distention implying urinary retention (cauda equina)
  • Reduced anal tone
• Key findings on examination for spinal infection

  • Localised tenderness to the spine (spinal fracture or cancer)
  • Bilateral neurological motor or sensory signs (cauda equina)
  • Bladder distention implying urinary retention (cauda equina)
  • Reduced anal tone on PR examination (cauda equina)
• Sciatic stretch test


  The patient lies on their back with their leg straight. The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees). Then the examiner dorsiflexes the patient’s ankle. Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation. Symptoms improve with flexing the knee
• Main cancers that metastasise to the bones

  • Prostate
  • Renal
  • Thyroid
  • Breast
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• Patients with mechanical/non-specific lower back pain can be diagnosed clinically and do not require further investigations
• Investigations for suspected ankylosing spondylitis

  1. Inflammatory markers (CRP and ESR)

  2. X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease)

  3. MRI of the spine (may show bone marrow oedema early in the disease)
• STarT Back Screening Tool

  The tool was developed by Keele University to stratify the risk of a patient presenting with acute back pain developing chronic back pain. It involves 9 questions that assess the patient’s function and psychological response to the back pain. It gives a total score (out of 9) and a subscore on the 4 psychosocial questions (out of 4). The interpretation gives a risk of developing chronic back pain: Low Risk, Medium Risk, High Risk
• Managing Acute Lower Back Pain

  First, exclude serious underlying causes. If concerned about symptoms or signs of an underlying condition, arrange further investigations and refer appropriately. For example: Same-day referral to the on-call orthopaedic team for an urgent MRI scan if cauda equina is suspected, Inflammatory markers and an urgent rheumatology review if ankylosing spondylitis is suspected, Full in-line spinal immobilisation, admission to a trauma unit and x-rays/CT scans for spinal injury after major trauma, Patients with neurological symptoms or signs on examination, particularly if progressive or severe, may require referral to orthopaedics or neurosurgery (potentially urgently), The StarT Back tool can be used to stratify the risk of developing chronic back pain
• Using the StarT Back tool


  Stratify the risk of developing chronic back pain
• Options for managing non-specific low back pain for patients at low risk

  • Self-management
  • Education
  • Reassurance
  • Analgesia
  • Staying active and continuing to mobilise as tolerated
• Additional options for managing non-specific low back pain for patients at medium or high risk

  • Physiotherapy
  • Group exercise
  • Cognitive behavioural therapy
• Recommended analgesia for low back pain

  • NSAIDs (e.g., ibuprofen or naproxen) first-line
  • Codeine as an alternative
  • Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)
• Do not use opioids, antidepressants, amitriptyline, gabapentin, or pregabalin for low back pain
• Patients need safety-net advice to report red flag symptoms, such as saddle anaesthesia or incontinence
• Radiofrequency denervation for chronic low back pain originating in the facet joints


  Radiofrequency is used to target and damage the medial branch nerves that supply sensation to the facet joints associated with the back pain. This is done under a local anaesthetic
• Management of Sciatica

  The initial management of sciatica is mostly the same as acute low back pain
• Do not use medications such as gabapentin, pregabalin, diazepam, or oral corticosteroids for sciatica
• Do not use opioids for chronic sciatica
• Consider a neuropathic medication if symptoms of sciatica are persisting or worsening at follow up, but not gabapentin or pregabalin. Main choices include Amitriptyline and Duloxetine
• Specialist management options for chronic sciatica

  • Epidural corticosteroid injections
  • Local anaesthetic injections
  • Radiofrequency denervation
  • Spinal decompression
• Last updated

  August 2021