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Sciatica and Radicular Back PainAPPROACH

BACK AND NECK · 19 SECTIONS

⚲

625 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Atraumatic Back Pain Sciatica And Radicular Back Pain Back Pain With Neurologic Deficit, Cauda Equina Concern Back Pain With Fever Or Immunosuppression, Spinal Infection Concern Atraumatic Neck Pain Neck Pain After Trauma Neck Pain With Meningismus Concern Acute Torticollis

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx76

Presenting symptoms

›Pattern and phenotype

›Low back pain with radiating leg pain below knee

›Dermatomal distribution

›Burning or electric pain quality

›Unilateral more common than bilateral

›Leg pain greater than back pain

›Neurogenic claudication pattern

›Worse with standing

›Worse with walking

›Better with sitting

›Better with lumbar flexion

›Functional impact

›Ambulation tolerance

›Sleep disruption

›Work limitations

›Driving tolerance

›Baseline and trajectory

›Prior episodes and recovery

›Baseline neurologic function

›Rapid progression timeline

OPQRST

›OPQRST framework

›Onset

›Sudden onset after lifting or twist

›Gradual onset over days to weeks

›Onset after trauma

›Onset after procedure

02Alarm Features/alarm55

Immediate escalation triggers

›Time critical spine emergencies

›Cauda equina syndrome features

›Urinary retention

›Saddle anesthesia

›Bilateral sciatica

›New fecal incontinence

›Reduced anal tone

›Progressive motor deficit

›Rapidly worsening weakness

›New foot drop

›Inability to dorsiflex

›Spinal epidural abscess features

›Fever or rigors

›Severe focal back pain

›Neurologic deficit

›Recent bacteremia risk

›Spinal epidural hematoma features

›Anticoagulation exposure

›Sudden severe back pain

›Rapid neurologic decline

›Malignancy related spinal cord compression features

›Known cancer history

›Night pain

›Weight loss

›Progressive neurologic deficit

›Unstable fracture features

›Significant trauma

03Medications/meds26

Current and recent medications

›Medication reconciliation focus

›Current prescribed analgesics

›Recent NSAID exposure

›Recent acetaminophen exposure

›Recent opioid exposure

›Recent muscle relaxant exposure

›Neuropathic agents exposure

›Recent corticosteroid exposure

›Bleeding and hematoma risks

›Anticoagulants

›Antiplatelets

›Recent thrombolytics

Contraindications and interaction traps

›NSAID contraindications

›Chronic kidney disease

›Heart failure

›Active GI bleeding risk

›Anticoagulation exposure

›Pregnancy third trimester

›Acetaminophen cautions

›Chronic liver disease

›Heavy alcohol use

›Sedating medication cautions

›Concurrent benzodiazepines

›Alcohol co use

›Sleep apnea risk

›Older adult fall risk

04Diet/diet9

Intake and exposures

›Hydration and intake patterns

›Reduced oral intake due to pain

›Dehydration symptoms

›Caffeine exposure

›Energy drinks

›High caffeine intake

›Alcohol exposure

›Recent heavy alcohol use

›Alcohol with sedating medications

05Review of Systems/ros31

Neurologic and musculoskeletal

›Neurologic symptoms

›Limb numbness

›Limb tingling

›Limb weakness

›Gait change

›New falls

›Spine and limb symptoms

›Midline spine pain

›Hip pain

›Knee pain

›Calf pain

›Morning stiffness

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Night sweats

›Weight loss

›Infectious symptoms

›Recent skin infection

›Recent urinary infection

›Recent respiratory infection

Genitourinary and gastrointestinal

›Bladder symptoms

›Urinary retention

›New incontinence

›Dysuria

06Collateral History and Family History/chafh13

Collateral and reliability

›Collateral sources

›Family or caregiver report

›EMS report

›Prior records review

›Reliability factors

›Cognitive impairment

›Intoxication

›Language barrier

Family history

›Relevant familial conditions

›Early cardiovascular disease

›Connective tissue disorders

›Inflammatory arthritis

›Malignancy syndromes

07Risk Factors/rf28

Mechanical and degenerative

›Mechanical contributors

›Recent lifting or twisting

›Occupational heavy labor

›Prolonged sitting

›Poor ergonomics

›Degenerative contributors

›Prior lumbar disc disease

›Known spinal stenosis

›Prior spine surgery

Infection and malignancy

›Infection risks

›Injection drug use

›Immunosuppression

›Diabetes mellitus

›Recent bacteremia

›Recent epidural injection

›Malignancy risks

›Known cancer

›Unexplained weight loss

›Night pain

›Age over 50

Thrombosis and vascular

›Vascular risks

›Known abdominal aortic aneurysm

›Hypertension

›Smoking history

›Thrombosis risks

08Differential Diagnosis/ddx66

Life threatening

›Spine and neurologic emergencies

›Cauda equina syndrome (G83.4)

›Urinary retention

›Saddle anesthesia

›Bilateral sciatica

›Spinal epidural abscess (G06.1)

›Fever

›Elevated inflammatory markers

›Neurologic deficit

›Spinal epidural hematoma (G95.1)

›Anticoagulation exposure

›Rapid deficit progression

›Malignant spinal cord compression (G95.20)

›Known malignancy

›Night pain

›Vertebral fracture (S22.0, S32.0)

›Trauma

›Osteoporosis

›Vascular catastrophes

›Abdominal aortic aneurysm rupture (I71.3)

›Hypotension

›Syncope

›Aortic dissection (I71.0)

›Sudden severe pain

›Pulse deficit

Common

›Radicular etiologies

09Past Medical History/pmh21

Relevant chronic conditions

›Spine and neurologic history

›Prior disc herniation

›Prior spinal stenosis

›Prior spine surgery

›Chronic neuropathy

›Comorbidities affecting risk and treatment

›Diabetes mellitus

›Chronic kidney disease

›Peptic ulcer disease

›Cardiovascular disease

›Cancer and infection history

›Active malignancy

›Prior metastatic disease

›Prior bacteremia

›Prior epidural abscess

Baseline function and supports

›Baseline function

›Independent ambulation status

›Baseline strength and sensory deficits

›Home situation

›Stairs and mobility barriers

›Caregiver support reliability

10Physical Exam/exam60

Vitals and general

›Global assessment

›Fever pattern

›Hemodynamic stability

›Toxic appearance

›Gait and posture

›Antalgic gait

›Foot drop gait

›Stooped posture

›Inability to heel walk

›Inability to toe walk

Back exam

›Spine and paraspinal findings

›Midline tenderness

›Paraspinal spasm

›Step off deformity

›Range of motion limitation

›Provocative patterns

›Pain with lumbar flexion

›Pain with lumbar extension

›Pain with cough

Neurologic exam

›Motor strength by myotome

›Hip flexion

›L2 to L3

›Knee extension

›L3 to L4

›Ankle dorsiflexion

11Lab Studies/labs21

When labs are indicated

›Infection or malignancy concern

›CBC

›CRP

›ESR

›Blood cultures if febrile or septic

›Bleeding risk or neurologic decline

›INR

›PTT

›Platelet count

›Pregnancy related considerations

›Urine pregnancy test

›Serum pregnancy test when needed

›Medication safety

›Creatinine and electrolytes for NSAID risk

›Liver enzymes for acetaminophen risk

Interpretation and pitfalls

›Inflammatory markers

›Normal values do not fully exclude early spinal infection

›Marked elevation increases concern for infection or malignancy

›Urinalysis when flank pain overlap

›Hematuria supports stone but is not required

›Pyuria supports infection

12Imaging/img42

Scoring Systems

›Imaging decision frameworks

›Red flag based imaging pathway

›Immediate imaging for cauda equina features

›Immediate imaging for progressive motor deficit

›Early imaging for suspected infection

›Early imaging for suspected malignancy

›Low back pain without red flags

›No routine imaging in first 6 weeks local protocol dependent

›Imaging for persistent symptoms with failed conservative therapy local protocol dependent

MRI

›MRI lumbar spine indications

›Cauda equina syndrome features

›Progressive or severe motor deficit

›Suspected epidural abscess

›Suspected epidural hematoma

›Suspected malignancy or cord compression

›Persistent radicular pain with planned intervention

›MRI protocol and pearls

›With and without gadolinium for infection or malignancy concern

›Disc herniation correlation required with dermatomal findings

›Incidental degenerative changes common

›MRI limitations

›Findings may not match symptoms

›Contraindicated with some implants local protocol dependent

›CT indications

›Fracture assessment when radiograph equivocal

13Special Tests/spec18

Radiculopathy maneuvers

›Straight leg raise

›Reproduction of radicular pain below knee

›Pain at lower angles increases likelihood

›Crossed straight leg raise

›Contralateral leg raise reproduces symptomatic side pain

›Higher specificity for disc herniation

›Slump test

›Neural tension reproduction

›Symptom change with neck extension release

›Femoral nerve stretch test

›Anterior thigh pain suggests upper lumbar radiculopathy

›Hip pathology confounders

Bladder evaluation for cauda equina

›Post void residual

›Elevated residual increases concern for retention

›Normal residual does not fully exclude early cauda equina

›Focused rectal exam local protocol dependent

›Anal tone

›Perianal sensation

14ECG/ecg7

When ECG is relevant

›Mimic and comorbidity screening

›Chest pain or syncope overlap

›Concern for aortic dissection with chest symptoms

›Older adult with vascular risk and atypical presentation

›Medication safety

›QT prolongation risk with certain antiemetics or psychotropics local protocol dependent

›Baseline rhythm assessment when opioid escalation in high risk patient local protocol dependent

15Assessment/ax22

Working diagnosis and severity

›Lumbar radiculopathy

›Sciatica due to disc herniation suspected (M51.16)

›Sciatica due to spinal stenosis suspected (M48.062)

›Severity stratification

›Pain severity and functional limitation

›Neurologic deficit presence

›Progressive deficit pattern

›Bladder or bowel dysfunction

›Complications to exclude

›Cauda equina syndrome

›Epidural abscess

›Epidural hematoma

›Malignancy compression

›Fracture

Key supporting and opposing features

›Supports radiculopathy

›Dermatomal pain distribution

›Positive neural tension test

›Corresponding motor or sensory deficit

›Supports alternative diagnosis

›Groin pain and hip ROM limitation

›Systemic symptoms

›Midline bony tenderness after trauma

16Plan/plan65

Differential Management

›!Lumbar radiculopathy→›!Cauda equina syndrome→

First 5 minutes and stabilization

›Critical pathway activation

›Escalate if cauda equina features present

›Escalate if progressive motor deficit present

›Escalate if sepsis physiology present

›Monitoring and access

›Continuous monitoring for unstable vitals

›IV access for severe pain needing parenteral therapy

›Time sensitive diagnostics

›MRI urgent for suspected cauda equina local protocol dependent

›MRI urgent for suspected epidural abscess local protocol dependent

Analgesia and symptom control

›Non opioid first line options

›Ibuprofen

›400 mg PO every 6 hours as needed

›Maximum 2400 mg per day

›Naproxen

›500 mg PO once

›Then 250 mg PO every 6 to 8 hours as needed

›Maximum 1000 mg per day

›Acetaminophen

›650 mg PO every 6 hours as needed

›Maximum 3000 mg per day

›Neuropathic pain agents local protocol dependent

›Gabapentin not routine first line for acute sciatica local protocol dependent

17Disposition/dispo25

Admission and higher level care

›ICU or monitored setting

›Hemodynamic instability

›Sepsis concern with neurologic symptoms

›Inpatient admission

›Suspected cauda equina syndrome

›Progressive motor deficit

›Suspected epidural abscess

›Suspected epidural hematoma

›Suspected malignant cord compression

›Intractable pain with inability to ambulate

›Unsafe discharge environment

Observation pathway local protocol dependent

›Short interval reassessment needs

›Severe pain requiring repeated parenteral analgesia

›Uncertain neurologic findings requiring repeat exam

›Pending urgent imaging availability

Discharge criteria and follow up

›Discharge criteria

›Stable vitals

›No red flag features

›No progressive motor deficit

›Ambulation safe

›Pain controlled with oral regimen

›Follow up timing

›Primary care or clinic follow up within 1 to 2 weeks

›Earlier follow up within 48 to 72 hours for borderline neurologic symptoms local protocol dependent

›Spine specialist referral if persistent symptoms beyond 4 to 6 weeks local protocol dependent

18Discharge Instructions/di25

Copy discharge instructions

›Diagnosis explanation

›Pain likely from irritation of a nerve in the low back causing pain down the leg

›Most cases improve over days to weeks

›Medications

›Use your anti inflammatory or acetaminophen as directed

›Do not take multiple anti inflammatory medicines at the same time

›Do not exceed the daily maximum dose of acetaminophen

›If given a sedating medicine

›No driving

›No alcohol

›Activity

›Stay active as tolerated

›Avoid heavy lifting until improving

›Short walks are often helpful

›Follow up

›Follow up with your clinician within 1 to 2 weeks

›Physical therapy may be recommended if symptoms persist

›Return to ED immediately for

›Trouble starting urination

›Loss of bladder control

›Loss of bowel control

›Numbness in the groin or saddle area

›New or worsening weakness in the leg or foot

›Fever with worsening back pain

›Severe pain with fainting or new chest pain

19References/r15

Guidelines and key sources

›NICE guideline NG59 low back pain and sciatica in over 16s 2016 updated 2020

›Imaging recommendations and red flag pathways

›Non surgical and interventional management

›American College of Physicians clinical practice guideline noninvasive treatments for acute subacute and chronic low back pain 2017

›First line nonpharmacologic options

›Medication considerations

›American College of Radiology Appropriateness Criteria low back pain 2021

›Imaging indications and modality selection

›Red flag and neurologic deficit pathways

›North American Spine Society guideline lumbar disc herniation with radiculopathy 2020

›Natural history and treatment options

›Interventional and surgical indications

›CDC clinical practice guideline for prescribing opioids for pain 2022

›Risk mitigation and duration principles

›Avoid high risk combinations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Sciatica and Radicular Back PainAPPROACH

BACK AND NECK · 19 SECTIONS

⚲

625 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx76

Presenting symptoms

›Pattern and phenotype

›Low back pain with radiating leg pain below knee

›Dermatomal distribution

›Burning or electric pain quality

›Unilateral more common than bilateral

›Leg pain greater than back pain

›Neurogenic claudication pattern

›Worse with standing

›Worse with walking

›Better with sitting

›Better with lumbar flexion

›Functional impact

›Ambulation tolerance

›Sleep disruption

›Work limitations

›Driving tolerance

›Baseline and trajectory

›Prior episodes and recovery

›Baseline neurologic function

›Rapid progression timeline

OPQRST

›OPQRST framework

›Onset

›Sudden onset after lifting or twist

›Gradual onset over days to weeks

›Onset after trauma

›Onset after procedure

02Alarm Features/alarm55

Immediate escalation triggers

›Time critical spine emergencies

›Cauda equina syndrome features

›Urinary retention

›Saddle anesthesia

›Bilateral sciatica

›New fecal incontinence

›Reduced anal tone

›Progressive motor deficit

›Rapidly worsening weakness

›New foot drop

›Inability to dorsiflex

›Spinal epidural abscess features

›Fever or rigors

›Severe focal back pain

›Neurologic deficit

›Recent bacteremia risk

›Spinal epidural hematoma features

›Anticoagulation exposure

›Sudden severe back pain

›Rapid neurologic decline

›Malignancy related spinal cord compression features

›Known cancer history

›Night pain

›Weight loss

›Progressive neurologic deficit

›Unstable fracture features

›Significant trauma

03Medications/meds26

Current and recent medications

›Medication reconciliation focus

›Current prescribed analgesics

›Recent NSAID exposure

›Recent acetaminophen exposure

›Recent opioid exposure

›Recent muscle relaxant exposure

›Neuropathic agents exposure

›Recent corticosteroid exposure

›Bleeding and hematoma risks

›Anticoagulants

›Antiplatelets

›Recent thrombolytics

Contraindications and interaction traps

›NSAID contraindications

›Chronic kidney disease

›Heart failure

›Active GI bleeding risk

›Anticoagulation exposure

›Pregnancy third trimester

›Acetaminophen cautions

›Chronic liver disease

›Heavy alcohol use

›Sedating medication cautions

›Concurrent benzodiazepines

›Alcohol co use

›Sleep apnea risk

›Older adult fall risk

04Diet/diet9

Intake and exposures

›Hydration and intake patterns

›Reduced oral intake due to pain

›Dehydration symptoms

›Caffeine exposure

›Energy drinks

›High caffeine intake

›Alcohol exposure

›Recent heavy alcohol use

›Alcohol with sedating medications

05Review of Systems/ros31

Neurologic and musculoskeletal

›Neurologic symptoms

›Limb numbness

›Limb tingling

›Limb weakness

›Gait change

›New falls

›Spine and limb symptoms

›Midline spine pain

›Hip pain

›Knee pain

›Calf pain

›Morning stiffness

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Night sweats

›Weight loss

›Infectious symptoms

›Recent skin infection

›Recent urinary infection

›Recent respiratory infection

Genitourinary and gastrointestinal

›Bladder symptoms

›Urinary retention

›New incontinence

›Dysuria

06Collateral History and Family History/chafh13

Collateral and reliability

›Collateral sources

›Family or caregiver report

›EMS report

›Prior records review

›Reliability factors

›Cognitive impairment

›Intoxication

›Language barrier

Family history

›Relevant familial conditions

›Early cardiovascular disease

›Connective tissue disorders

›Inflammatory arthritis

›Malignancy syndromes

07Risk Factors/rf28

Mechanical and degenerative

›Mechanical contributors

›Recent lifting or twisting

›Occupational heavy labor

›Prolonged sitting

›Poor ergonomics

›Degenerative contributors

›Prior lumbar disc disease

›Known spinal stenosis

›Prior spine surgery

Infection and malignancy

›Infection risks

›Injection drug use

›Immunosuppression

›Diabetes mellitus

›Recent bacteremia

›Recent epidural injection

›Malignancy risks

›Known cancer

›Unexplained weight loss

›Night pain

›Age over 50

Thrombosis and vascular

›Vascular risks

›Known abdominal aortic aneurysm

›Hypertension

›Smoking history

›Thrombosis risks

08Differential Diagnosis/ddx66

Life threatening

›Spine and neurologic emergencies

›Cauda equina syndrome (G83.4)

›Urinary retention

›Saddle anesthesia

›Bilateral sciatica

›Spinal epidural abscess (G06.1)

›Fever

›Elevated inflammatory markers

›Neurologic deficit

›Spinal epidural hematoma (G95.1)

›Anticoagulation exposure

›Rapid deficit progression

›Malignant spinal cord compression (G95.20)

›Known malignancy

›Night pain

›Vertebral fracture (S22.0, S32.0)

›Trauma

›Osteoporosis

›Vascular catastrophes

›Abdominal aortic aneurysm rupture (I71.3)

›Hypotension

›Syncope

›Aortic dissection (I71.0)

›Sudden severe pain

›Pulse deficit

Common

›Radicular etiologies

09Past Medical History/pmh21

Relevant chronic conditions

›Spine and neurologic history

›Prior disc herniation

›Prior spinal stenosis

›Prior spine surgery

›Chronic neuropathy

›Comorbidities affecting risk and treatment

›Diabetes mellitus

›Chronic kidney disease

›Peptic ulcer disease

›Cardiovascular disease

›Cancer and infection history

›Active malignancy

›Prior metastatic disease

›Prior bacteremia

›Prior epidural abscess

Baseline function and supports

›Baseline function

›Independent ambulation status

›Baseline strength and sensory deficits

›Home situation

›Stairs and mobility barriers

›Caregiver support reliability

10Physical Exam/exam60

Vitals and general

›Global assessment

›Fever pattern

›Hemodynamic stability

›Toxic appearance

›Gait and posture

›Antalgic gait

›Foot drop gait

›Stooped posture

›Inability to heel walk

›Inability to toe walk

Back exam

›Spine and paraspinal findings

›Midline tenderness

›Paraspinal spasm

›Step off deformity

›Range of motion limitation

›Provocative patterns

›Pain with lumbar flexion

›Pain with lumbar extension

›Pain with cough

Neurologic exam

›Motor strength by myotome

›Hip flexion

›L2 to L3

›Knee extension

›L3 to L4

›Ankle dorsiflexion

11Lab Studies/labs21

When labs are indicated

›Infection or malignancy concern

›CBC

›CRP

›ESR

›Blood cultures if febrile or septic

›Bleeding risk or neurologic decline

›INR

›PTT

›Platelet count

›Pregnancy related considerations

›Urine pregnancy test

›Serum pregnancy test when needed

›Medication safety

›Creatinine and electrolytes for NSAID risk

›Liver enzymes for acetaminophen risk

Interpretation and pitfalls

›Inflammatory markers

›Normal values do not fully exclude early spinal infection

›Marked elevation increases concern for infection or malignancy

›Urinalysis when flank pain overlap

›Hematuria supports stone but is not required

›Pyuria supports infection

12Imaging/img42

Scoring Systems

›Imaging decision frameworks

›Red flag based imaging pathway

›Immediate imaging for cauda equina features

›Immediate imaging for progressive motor deficit

›Early imaging for suspected infection

›Early imaging for suspected malignancy

›Low back pain without red flags

›No routine imaging in first 6 weeks local protocol dependent

›Imaging for persistent symptoms with failed conservative therapy local protocol dependent

MRI

›MRI lumbar spine indications

›Cauda equina syndrome features

›Progressive or severe motor deficit

›Suspected epidural abscess

›Suspected epidural hematoma

›Suspected malignancy or cord compression

›Persistent radicular pain with planned intervention

›MRI protocol and pearls

›With and without gadolinium for infection or malignancy concern

›Disc herniation correlation required with dermatomal findings

›Incidental degenerative changes common

›MRI limitations

›Findings may not match symptoms

›Contraindicated with some implants local protocol dependent

›CT indications

›Fracture assessment when radiograph equivocal

13Special Tests/spec18

Radiculopathy maneuvers

›Straight leg raise

›Reproduction of radicular pain below knee

›Pain at lower angles increases likelihood

›Crossed straight leg raise

›Contralateral leg raise reproduces symptomatic side pain

›Higher specificity for disc herniation

›Slump test

›Neural tension reproduction

›Symptom change with neck extension release

›Femoral nerve stretch test

›Anterior thigh pain suggests upper lumbar radiculopathy

›Hip pathology confounders

Bladder evaluation for cauda equina

›Post void residual

›Elevated residual increases concern for retention

›Normal residual does not fully exclude early cauda equina

›Focused rectal exam local protocol dependent

›Anal tone

›Perianal sensation

14ECG/ecg7

When ECG is relevant

›Mimic and comorbidity screening

›Chest pain or syncope overlap

›Concern for aortic dissection with chest symptoms

›Older adult with vascular risk and atypical presentation

›Medication safety

›QT prolongation risk with certain antiemetics or psychotropics local protocol dependent

›Baseline rhythm assessment when opioid escalation in high risk patient local protocol dependent

15Assessment/ax22

Working diagnosis and severity

›Lumbar radiculopathy

›Sciatica due to disc herniation suspected (M51.16)

›Sciatica due to spinal stenosis suspected (M48.062)

›Severity stratification

›Pain severity and functional limitation

›Neurologic deficit presence

›Progressive deficit pattern

›Bladder or bowel dysfunction

›Complications to exclude

›Cauda equina syndrome

›Epidural abscess

›Epidural hematoma

›Malignancy compression

›Fracture

Key supporting and opposing features

›Supports radiculopathy

›Dermatomal pain distribution

›Positive neural tension test

›Corresponding motor or sensory deficit

›Supports alternative diagnosis

›Groin pain and hip ROM limitation

›Systemic symptoms

›Midline bony tenderness after trauma

16Plan/plan65

Differential Management

›!Lumbar radiculopathy→›!Cauda equina syndrome→

First 5 minutes and stabilization

›Critical pathway activation

›Escalate if cauda equina features present

›Escalate if progressive motor deficit present

›Escalate if sepsis physiology present

›Monitoring and access

›Continuous monitoring for unstable vitals

›IV access for severe pain needing parenteral therapy

›Time sensitive diagnostics

›MRI urgent for suspected cauda equina local protocol dependent

›MRI urgent for suspected epidural abscess local protocol dependent

Analgesia and symptom control

›Non opioid first line options

›Ibuprofen

›400 mg PO every 6 hours as needed

›Maximum 2400 mg per day

›Naproxen

›500 mg PO once

›Then 250 mg PO every 6 to 8 hours as needed

›Maximum 1000 mg per day

›Acetaminophen

›650 mg PO every 6 hours as needed

›Maximum 3000 mg per day

›Neuropathic pain agents local protocol dependent

›Gabapentin not routine first line for acute sciatica local protocol dependent

17Disposition/dispo25

Admission and higher level care

›ICU or monitored setting

›Hemodynamic instability

›Sepsis concern with neurologic symptoms

›Inpatient admission

›Suspected cauda equina syndrome

›Progressive motor deficit

›Suspected epidural abscess

›Suspected epidural hematoma

›Suspected malignant cord compression

›Intractable pain with inability to ambulate

›Unsafe discharge environment

Observation pathway local protocol dependent

›Short interval reassessment needs

›Severe pain requiring repeated parenteral analgesia

›Uncertain neurologic findings requiring repeat exam

›Pending urgent imaging availability

Discharge criteria and follow up

›Discharge criteria

›Stable vitals

›No red flag features

›No progressive motor deficit

›Ambulation safe

›Pain controlled with oral regimen

›Follow up timing

›Primary care or clinic follow up within 1 to 2 weeks

›Earlier follow up within 48 to 72 hours for borderline neurologic symptoms local protocol dependent

›Spine specialist referral if persistent symptoms beyond 4 to 6 weeks local protocol dependent

18Discharge Instructions/di25

Copy discharge instructions

›Diagnosis explanation

›Pain likely from irritation of a nerve in the low back causing pain down the leg

›Most cases improve over days to weeks

›Medications

›Use your anti inflammatory or acetaminophen as directed

›Do not take multiple anti inflammatory medicines at the same time

›Do not exceed the daily maximum dose of acetaminophen

›If given a sedating medicine

›No driving

›No alcohol

›Activity

›Stay active as tolerated

›Avoid heavy lifting until improving

›Short walks are often helpful

›Follow up

›Follow up with your clinician within 1 to 2 weeks

›Physical therapy may be recommended if symptoms persist

›Return to ED immediately for

›Trouble starting urination

›Loss of bladder control

›Loss of bowel control

›Numbness in the groin or saddle area

›New or worsening weakness in the leg or foot

›Fever with worsening back pain

›Severe pain with fainting or new chest pain

19References/r15

Guidelines and key sources

›NICE guideline NG59 low back pain and sciatica in over 16s 2016 updated 2020

›Imaging recommendations and red flag pathways

›Non surgical and interventional management

›American College of Physicians clinical practice guideline noninvasive treatments for acute subacute and chronic low back pain 2017

›First line nonpharmacologic options

›Medication considerations

›American College of Radiology Appropriateness Criteria low back pain 2021

›Imaging indications and modality selection

›Red flag and neurologic deficit pathways

›North American Spine Society guideline lumbar disc herniation with radiculopathy 2020

›Natural history and treatment options

›Interventional and surgical indications

›CDC clinical practice guideline for prescribing opioids for pain 2022

›Risk mitigation and duration principles

›Avoid high risk combinations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.