PONOS · SPINAL PAIN
Sciatica and lumbar radiculopathy
Radiating pain, tingling and weakness: understanding the cause to choose appropriate treatment.
Radiculopathy affects the function of lumbar or sacral nerve roots. It may involve sensation, strength and reflexes, and may be accompanied by pain.
The specialist pathway
Pain, tingling and weakness: three different findings
Pain may radiate from the buttock down the leg. Tingling is an abnormal sensation; hypoesthesia means reduced sensation. Weakness is a motor deficit: for example, it may make lifting the foot difficult. These symptoms can coexist, but they should not be confused or treated as equivalent measures of treatment outcome.
What can cause it?
Possible causes include disc herniation, narrowing of the spinal canal or foramina, degenerative changes and conditions following surgery. An MRI finding alone does not establish the source of symptoms: it must agree with the clinical assessment.
Identifying the affected nerve root
The assessment reviews onset, symptom distribution and previous operations, and examines strength, sensation and reflexes. Pain location helps guide the diagnosis but does not identify the responsible root on its own.
MRI must be interpreted alongside the clinical findings. It is not automatically needed for every episode of sciatica; in specialist care it is requested when it may change management. Electromyography can help resolve diagnostic uncertainty or distinguish a nerve root problem from a peripheral neuropathy, without replacing examination.
Which treatments may be considered?
Activity, rehabilitation and medication
Initial care may include adapted activity, exercise and rehabilitation, with medication selected according to the clinical findings and individual risks. A diagnosis of neuropathic pain does not automatically make every medicine used for other neuropathies appropriate. Benefit and tolerability should be reviewed.
Selective injections
Epidural injections of local anaesthetic and corticosteroid may be considered for acute, severe sciatica. The target and imaging guidance depend on the indication and anatomy. The aim is pain relief; injections do not guarantee resolution of compression or recovery of strength.
Epidural and nerve root injections (Italian)
Pulsed radiofrequency and epidural adhesiolysis
In selected persistent cases, pulsed radiofrequency of the nerve root or dorsal root ganglion may be discussed. Individual assessment is essential: this treatment is not necessary for every episode of sciatica and does not remove mechanical compression. Results and duration of benefit vary.
Epidural adhesiolysis concerns specific situations, including after surgery, where epidural adhesions may contribute. It is not an obligatory step. These procedures are not equivalent, and the cases below do not establish universal effectiveness.
When surgical assessment is needed
Decompression may be considered when non-surgical treatment has not improved pain or function and imaging is consistent with symptoms. New or worsening motor deficits require prompt assessment without waiting to complete a pain management pathway.
Two L5 cases, two different situations
Right L5 after spinal fusion: continuous tingling
Following an initial period of improvement, tingling began two months after surgery. Approximately five years after fusion, PRF was performed in the context of substantial periradicular fibrosis. At the three-week review, resolution of tingling was documented. This does not establish recovery of strength or a long-term outcome.
Left L5 and lumbar stenosis in an older patient
In the 86-year-old patient treated with adhesiolysis and PRF, radicular pain was in remission at six and twelve months. Reported walking distance increased from 30–50 metres to approximately 1,000 metres at three months and 500 metres at one year. Stenosis and reduced sensation persisted; motor recovery was not documented. Combined treatment does not allow the contribution of each procedure to be separated.
Symptoms that should not wait
New difficulty passing urine, loss of bladder or bowel control, loss of sensation around the genitals or anus, or severe or rapidly progressive leg weakness require urgent emergency assessment.
Preparing for the appointment and assessing outcomes
Bring images and reports, any operative report, and a list of medication and previous treatments. Describe pain, tingling, reduced sensation and motor difficulties separately, including when they started.
Follow-up compares the same findings, together with walking, sleep and daily activities. One symptom may improve while others persist: pain relief must not distract from increasing weakness.
Sources and further reading
- NICE NG59 — Low back pain and sciatica: assessment and management (assessment, conservative care, epidural injections and surgery; not a source of a specific PRF recommendation).
- NHS — Sciatica: symptoms and warning signs.
- Lumbar spinal stenosis (Italian).
- Pain after lumbar spine surgery.
A pathway based on your clinical findings
Dr Evangelos Panagiotakos MD
Anaesthesiologist – Interventional Pain Specialist