Neurology

Radiculopathy

Radiculopathy is dysfunction of a spinal nerve root causing radiating pain, sensory change, weakness or reflex loss in a root distribution; most lumbar sciatica improves with conservative care, but cauda equina, cord compression, progressive deficit, infection and malignancy require urgent escalation.

In a nutshell

Radiculopathy is a spinal nerve-root syndrome causing radiating pain with possible dermatomal sensory loss, myotomal weakness and reflex change. Most uncomplicated sciatica improves with staying active and exercise-based care. Do not use gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for sciatica, and do not use opioids for chronic sciatica. Bilateral symptoms, saddle sensory change, bladder or bowel dysfunction, progressive weakness, cord signs, infection or malignancy require urgent escalation.

Classic presentation

A person has sharp pain radiating from the lower back or buttock into one leg, with paraesthesia and a root-related weakness or reflex change. Ask directly about saddle sensation, urination, bowel control, bilateral weakness, gait, fever, cancer and trauma.

Key points

Localise clinically using pain, sensation, power, reflexes and nerve-tension signs; correlate any MRI abnormality with the examination.
Most uncomplicated lumbar radiculopathy improves over weeks to months and does not need routine imaging in a non-specialist setting.
NICE advises against gabapentinoids, other antiepileptics, oral corticosteroids and benzodiazepines for sciatica, and against opioids for chronic sciatica.
If an NSAID is used for sciatica, discuss limited benefit and gastrointestinal, renal, hepatic and cardiovascular risks and use the lowest effective dose briefly.
Consider an epidural local anaesthetic and steroid for acute severe sciatica after specialist assessment; do not use it for nonspecific low back pain or neurogenic claudication.
Consider decompression when pain or function has not improved and concordant imaging supports the clinical syndrome.
Bilateral sciatica, saddle numbness, urinary initiation or retention problems, incontinence, bowel-control change or severe worsening bilateral weakness is an emergency cauda-equina pattern.
Gait disturbance, brisk reflexes, extensor plantars, a sensory level or new bladder and bowel symptoms suggest cord disease rather than simple radiculopathy.
Fever, immunosuppression, cancer, weight loss, trauma or constant night pain require an alternative serious-cause pathway.

First-line investigation

Focused neurological and red-flag examination; reserve routine MRI and other tests for serious pathology, progressive or disabling symptoms, diagnostic uncertainty or planned intervention, with emergency imaging for suspected cauda equina or cord compression.

Management

Exclude cauda equina and cord emergencies

Ask about bilateral symptoms, saddle sensation, bladder and bowel dysfunction, progressive weakness and gait; arrange emergency hospital review and urgent MRI if cauda equina or myelopathy is possible.^4,1,3

Support uncomplicated sciatica

Explain the usual favourable course, encourage normal activity and exercise, and use physiotherapy or manual therapy only within an exercise-based package.^2,3

Avoid ineffective or harmful sciatica medicines

Do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for sciatica, and do not offer opioids for chronic sciatica; if an NSAID is used, assess risks and use it briefly and cautiously.^2,5

Consider epidural or surgery selectively

Consider an epidural for acute severe sciatica and decompression for persistent pain or functional impairment when specialist imaging is concordant; progressive motor deficits need specialist review.^2,1

Review and safety-net

Review pain, function, neurological deficit and recovery trajectory, and give explicit emergency advice for new saddle symptoms, urinary or bowel dysfunction, bilateral weakness, gait change, fever or systemic illness.^2,1,3

Exam traps

A positive straight-leg raise supports nerve irritation but is not sufficient to diagnose or localise a root alone.
An incidental disc abnormality is not automatically the pain generator; correlate the level and side with the examination.
Cauda equina symptoms require emergency assessment and urgent MRI, not a routine outpatient referral.
Cervical radiculopathy with gait change, clumsy hands, brisk reflexes, extensor plantars or bladder disturbance may be myelopathy.
Epidural injection is for acute severe sciatica, not nonspecific low back pain or neurogenic claudication from central stenosis.
Do not stop long-term opioids, gabapentinoids or benzodiazepines abruptly; discuss risks and safe withdrawal.

Illustrations

Lumbar disc prolapse on MRISagittal lumbar MRI showing lower-lumbar disc protrusions indenting the ventral thecal sac, with an educational annotation that radiological abnormalities are common and need clinical correlation.Miguel Tremblay, Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.