What I Treat
Low Back Pain & Sciatica
From symptom to the right decision
Low back pain and sciatica are two distinct syndromes that often present together. Low back pain is axial pain centred between the lower ribs and gluteal folds, often mechanical and non-specific. Sciatica is leg-dominant pain from irritation or compression of a lumbosacral nerve root, most commonly L5 or S1, and may include sensory, motor or reflex changes. The first step in any consultation is deciding which syndrome you are treating.
Approach
Sort the patient first
Back pain and sciatica are symptoms, not a diagnosis. The first clinical task is always to sort the patient into one of three categories, because each demands a fundamentally different response.
Danger
Cauda equina syndrome, progressive neurological deficit, spinal infection, malignancy, or fracture. These patients need same-day MRI and specialist review — not a trial of physiotherapy.
Root
Dermatomal leg pain with tension signs and focal neurological change. Most commonly L5 or S1. MRI genuinely informs management here because the clinical picture localises a likely compressive lesion.
Mechanical
Axial pain, movement-related, no convincing root deficit or red flags. This is the largest group. The best intervention is a structured recovery plan — not a scan.
Assessment
Clinical examination
The examination begins with the history. The physical findings that follow either confirm or challenge your working diagnosis — they are not a checklist to be completed in isolation.
History
- •Pain map and dermatomal distribution
- •Provoking and relieving factors
- •Bladder, bowel, and sexual function
- •Systemic symptoms (fever, weight loss, night pain)
- •Past history of cancer, trauma, osteoporosis, inflammatory disease
Physical
- •Straight-leg raise and crossed SLR
- •Motor: L4 knee (quadriceps), L5 great-toe (extensor hallucis longus), S1 plantar (gastrocnemius-soleus)
- •Reflexes: patellar (L3/L4), Achilles (S1)
- •Dermatomal light touch and pinprick sensation
- •Saddle region sensation and anal tone
- •Gait, heel walking, toe walking
Emergency
Red flags — cauda equina syndrome
Cauda equina syndrome is a neurosurgical emergency. The following features demand immediate assessment:
- •New difficulty initiating or controlling urination
- •Altered urinary sensation or awareness of bladder filling
- •Saddle sensory change or numbness
- •Bilateral lower-limb symptoms
- •Sexual dysfunction of new onset
- •Progressive motor weakness in the legs
These require urgent MRI and urgent spinal review. Do not wait for a routine outpatient appointment.
Imaging
MRI is a clinical question
An MRI scan is not a routine investigation for back pain. It is a targeted test ordered to answer a specific clinical question that the history and examination have already framed.
When to scan
- •No routine MRI in acute, uncomplicated low back pain or sciatica without red flags
- •MRI indicated when it will change care: persistent disabling symptoms despite structured conservative management
- •Intervention planning (epidural, surgical)
- •Diagnostic uncertainty or incongruent clinical picture
- •Urgent MRI for suspected cauda equina, infection, malignancy, or progressive deficit
Demand concordance
A scan finding without clinical correlation is noise, not signal. The level, side, and nerve root compressed must match the patient’s symptoms and examination findings.
A disc bulge or degenerative change visible on MRI does not explain pain unless it matches the clinical picture. A discordant scan does not explain the patient’s pain — it distracts from the real diagnosis.
Clinical examination and history remain the foundation of diagnosis. The scan is a supporting investigation, not a substitute for clinical reasoning.
Management
Active recovery
Most patients with low back pain and sciatica improve with time and structured support, not with a procedure. Active recovery is built on four principles.
Understanding
Explain the diagnosis in plain language. Describe the expected natural course and give clear safety-net advice so the patient knows when to return. Fear and uncertainty amplify pain — knowledge reduces both.
Movement
Continue normal activity within tolerable limits. Avoid prolonged bed rest, which causes deconditioning and prolongs disability. The spine is designed to move — gentle, graduated activity is therapeutic.
Rebuild
Graded exercise, strength work, mobility, and confidence-building. The goal is not pain elimination but functional restoration. Core stability, lower-limb strength, and general conditioning underpin durable recovery.
Review
Track function and neurology, not pain scores alone. Improvement in what the patient can do is the real measure of recovery. Deterioration in motor or sphincter function demands urgent reassessment.
Escalation
Treatment intensity
Treatment is stepped according to the category of back pain, severity, duration, and response to earlier measures. Each step is only considered when the previous tier has been genuinely trialled and found insufficient.
Foundation tier
Education, activity modification, exercise, sleep optimisation, return-to-work planning, and identification of psychosocial barriers to recovery. This is not “doing nothing” — it is the active, evidence-based first line for the vast majority of patients.
Medicines
NSAIDs when appropriate, for the shortest effective duration and at the lowest effective dose. Oral steroids for acute severe radicular pain in selected cases.
Avoid routine gabapentinoids, oral steroids, and benzodiazepines for sciatica — the evidence does not support their routine use, and their harms are well-established. Opioids have a limited role and should not be a long-term strategy.
Interventional
Image-guided epidural steroid injection for selected patients with acute severe sciatica where pain limits engagement with active rehabilitation. This is a temporising measure that facilitates recovery — it is not a standalone treatment and does not alter the long-term natural history of disc herniation.
Surgery
Reserved for emergency neurology (cauda equina syndrome, rapidly progressive motor deficit) or for persistent, disabling, concordant radicular symptoms that have not responded to adequate non-surgical care. Surgery for axial back pain alone has a far less predictable outcome.
Decision-making
When surgery is discussed
Surgery for degenerative spine conditions is elective. The decision rests on three principles, and all three should be satisfied before a date is booked.
Microdiscectomy is most effective for concordant radicular leg pain. It is less predictable for isolated numbness, motor recovery, or axial back pain. These are reasonable aims, but they should not be the primary indication.
Never promise a “new back.”
Principles
Five rules
Medical disclaimer: The information on this page is for general educational purposes only. It is not a substitute for individual medical advice, diagnosis, or treatment. Always consult your own doctor or specialist with any questions you may have regarding a medical condition.