Synopsis
Diagnose cervical and lumbar nerve-root syndromes clinically, identify cord and cauda-equina emergencies and use imaging, medicines, activity and surgery according to disability and concordant anatomy.
- Radiculopathy is a nerve-root syndrome producing dermatomal pain or sensory symptoms, myotomal weakness and a corresponding reflex change; pain without objective deficit may still be radicular.
- Disc prolapse is one cause among foraminal stenosis, osteophyte, tumour, infection, inflammation and postoperative scar; an MRI disc bulge is common and does not prove symptom causation.
- Cervical roots cause neck-to-arm pain, paraesthesia and segmental weakness; lumbar roots cause back-to-leg sciatica, with L5 and S1 common but clinically overlapping.
- A positive straight-leg raise reproduces familiar radicular pain below the knee; the crossed test is less sensitive but more specific for a disc-related syndrome.
- Check for cervical myelopathy whenever arm radiculopathy is accompanied by gait disturbance, clumsy hands or legs, brisk reflexes, extensor plantars or sphincter change.
- Most uncomplicated disc-related radiculopathy improves over weeks with information, continued activity and exercise; prolonged bed rest promotes deconditioning and fear.
- NICE advises against routine imaging in non-specialist low-back and sciatica care; MRI is used when serious pathology is suspected or specialist results will change invasive management.
- For sciatica, NICE advises against gabapentinoids, other antiepileptics, oral corticosteroids and benzodiazepines because overall benefit is lacking and harm exists.
- Consider epidural local anaesthetic plus steroid only for acute severe sciatica through an appropriate service, not routine non-specific back pain.
- Spinal decompression is considered when non-surgical treatment has not improved pain or function and radiology is concordant; progressive motor deficit prompts earlier surgical review.
Key red flags
Bilateral sciatica or progressive weakness accompanies saddle, genital, urinary flow, bowel fullness or sexual dysfunction and requires emergency MRI rather than routine conservative care.
Hand clumsiness, gait disturbance, brisk legs, clonus, extensor plantars or new bladder change with arm symptoms indicates myelopathy beyond an isolated root.
Unremitting night pain, weight loss, known malignancy, fever, immunosuppression, injecting drug use or recent spinal infection and procedure demands a cause-specific urgent pathway.
Investigation priorities
Demonstrate a coherent myotomal, dermatomal and reflex pattern and exclude myelopathy or cauda-equina disease.
Management branches
Neck-to-arm or back-to-leg pain suggests a nerve-root syndrome.
- Define distribution, onset, cough or movement provocation and functional loss, then test myotomes, reflexes, sensation and tension signs and screen cord, cauda-equina, cancer, infection and trauma features.
- Use emergency MRI and specialist routes for red flags; otherwise explain the favourable natural history, encourage normal activity and avoid routine non-specialist imaging.
- Offer goal-based exercise and self-management, review work and sleep and use short, risk-assessed analgesia rather than prolonged bed rest or automatic dependence-forming medicine.