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Lumbar radiculopathy (sciatica) — MSRA MCQ

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HardMRILumbar radiculopathy (sciatica)MSRA

A 46-year-old warehouse supervisor presents with 10 weeks of left-sided leg pain. It began with low back pain but is now predominantly a sharp, burning pain from the left buttock to the lateral calf and dorsum of the foot. The pain is preventing sleep and he has been unable to work despite remaining active where possible, a trial of ibuprofen with gastroprotection, and a supervised exercise programme. He has no fever, weight loss, history of cancer, recent trauma, immunosuppression or intravenous drug use. He reports no saddle sensory disturbance, bladder or bowel dysfunction, gait deterioration or progressive weakness. Examination shows an antalgic gait due to pain, normal lower-limb power, reflexes and sensation, and a positive left straight-leg raise. He can undergo MRI. What is the most appropriate next management and imaging plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Refer to a specialist musculoskeletal or spinal service without requesting MRI from primary care

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · C = shown as D · A = shown as E

This is persistent, disabling lumbar radicular pain (sciatica), with pain inadequately controlled by appropriate initial management. Referral to a specialist musculoskeletal or spinal service is therefore appropriate. However, he has no features suggesting serious spinal pathology: there is no cancer history or constitutional illness, infection risk, trauma, progressive neurological deficit, or cauda equina symptoms. NICE advises against routine imaging in non-specialist settings for low back pain with or without sciatica. Imaging can be considered in a specialist setting if it is likely to alter management, for example when contemplating decompression for radiologically concordant, persistent sciatica. A is attractive because symptoms are prolonged and clinically radicular, but primary-care MRI is not routinely indicated in the absence of suspected serious pathology. C fails because his symptoms are already disabling and uncontrolled, meeting the threshold for referral. D is inappropriate without suspected malignancy. E would be correct with new bladder or bowel dysfunction, saddle sensory loss, or progressive bilateral neurological deficit suggesting cauda equina syndrome.

Reference: Low back pain and sciatica in over 16s: assessment and management — Recommendations (Updated 2020) — https://www.nice.org.uk/guidance/NG59/chapter/recommendations Low back pain and sciatica in over 16s: assessment and management — Recommendations (Updated 2020) — https://www.nice.org.uk/guidance/NG59/chapter/recommendations Suspected neurological conditions: recognition and referral — Recommendations for adults aged over 16 (2019) — https://www.nice.org.uk/guidance/ng127/chapter/Recommendations-for-adults-aged-over-16