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Chronic Radiculopathy — FRCA Final MCQ

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HardPain MedicineChronic RadiculopathyFRCA Final

A 38-year-old man has had persistent, function-limiting, unilateral L5-distribution leg pain for 3 years. His pain is predominantly radicular rather than localised axial back pain. MRI demonstrates an L4/5 disc protrusion compressing the corresponding nerve root, concordant with his symptoms. Structured non-surgical treatment has not improved his pain or function, and he has not previously undergone lumbar surgery or spinal surgical assessment. According to NICE NG59, which referral or intervention should now be considered specifically to treat the compressive sciatica?

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Correct answer: D — Referral for a spinal surgical opinion regarding decompression or discectomy

The correct answer is D. NICE NG59 recommends considering spinal decompression when non-surgical treatment has failed to improve pain or function and imaging findings are concordant with the sciatic symptoms. In this case, persistent L5 radiculopathy and matching L4/5 nerve-root compression meet those criteria; discectomy is a form of decompression for disc-related compression. Epidural local anaesthetic and steroid injections are recommended only for acute severe sciatica, not repeated treatment of chronic radiculopathy. Radiofrequency denervation targets localised medial-branch-mediated axial back pain and requires a positive diagnostic medial branch block. Although NICE TA159 permits spinal cord stimulation for selected refractory neuropathic pain, it requires specified pain severity, multidisciplinary assessment and a successful trial; it should not displace assessment of a surgically remediable compressive lesion. Intrathecal drug delivery is not recommended by NG59 for this indication.

Reference: NICE. Low back pain and sciatica in over 16s: assessment and management (NG59), recommendations 1.3.5 and 1.3.8. Published 2016; last updated 2020. https://www.nice.org.uk/guidance/NG59/chapter/recommendations