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Sciatica (lumbar radiculopathy) - Management
How should I assess someone with sciatica for immediate serious risks (red flags)?
When assessing people with sciatica, check for the presence of 'red flags' for serious conditions, and if any are present, refer or admit the person with appropriate urgency.
Red flags that suggest cauda equina syndrome
- From medical history:
- Saddle anaesthesia or paraesthesia.
- Recent onset of bladder dysfunction (the bladder distends because sensation of fullness is lost; bladder control is lost because there is no sensation when passing urine).
- Recent onset of faecal incontinence (due to loss of sensation of rectal fullness).
- From physical examination:
- Perianal/perineal sensory loss.
- Unexpected laxity of the anal sphincter.
- Severe or progressive neurological deficit in the lower extremities, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
Red flags that suggest spinal fracture
- From medical history:
- Sudden onset of severe central pain in the spine which is relieved by lying down.
- Major trauma such as a road accident or fall from a height.
- Minor trauma, or even just strenuous lifting, in people with osteoporosis.
- From physical examination:
- Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra).
Red flags that suggest cancer or infection
- From medical history:
- Onset in people older than 50 years, or younger than 20 years, of age.
- History of cancer.
- Constitutional symptoms, such as fever, chills, or unexplained weight loss.
- Recent bacterial infection (for example urinary tract infection).
- Intravenous drug abuse.
- Immune suppression.
- Pain that remains when supine, aching night-time pain that disturbs sleep, and thoracic pain (which also suggests aortic aneurysm).
- From physical examination:
- Structural deformity of the spine (such as scoliosis).
Red flags that suggest a high risk of permanent damage to the compressed nerve
- Significant muscle weakness or wasting.
- Loss of tendon reflexes.
- Presence of a positive Babinski reflex — when the lateral part of the sole of the foot is stimulated, the toes extend and fan outwards.
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