Nerve Root Pain / Sciatica

Back pain is a very common problem in the UK - with eight out of ten people suffering from it at some point during their lives.

It can affect anyone, at any age, and is usually caused by a sprain or a strain of the muscles, ligaments, joints or discs in the back. Most of us know that this can be very painful, and inconvenient, but it is not serious.

Back pain is classified as acute or chronic, depending on how long the pain has been present. Acute pain is shorter lived and more common. We call back pain chronic once it has been has been present for more than 3 months. Managing back pain well prevents people developing chronic back pain.

Most people experience back pain on one or both sides of their backs but may also feel it around their hips and buttocks and occasionally into one or both thighs. But with simple advice, most people will see a great improvement in their back pain within two weeks.

Chronic back pain can last much longer and usually requires treatment such as medication or physiotherapy. In most cases though, your back will heal itself. It is important that you keep active and continue as normal.

National Back Pain and Radicular Pain Pathway


  • Assessment, treatment, and management of nerve root pain / sciatica not attributed to a serious pathology in adults within primary care.

Out of scope


Differentiate between Red Flags (See Red Flags section), nonspecific low back pain (NSLBP) and nerve root pain (sciatica)

Guidance on assessment of LBP for GP

History taking is most important in differentiating NSLBP from nerve root pain or stenotic leg pain and serious pathology.

If low severity symptoms, reassure patients that prognosis is good within 6/52 period See guidance on managing low risk patients

  • good prognosis
  • advice and information on self-management (see patient information below)
  • pain management
  • activity modification, but reassurance pain not damaging, stay at work if possible (even if modification required)
  • referral should not be required on first contact

If medium or high severity of symptoms;

  • advice as above PLUS refer to physiotherapy if symptoms persisting at 2 weeks
  • Physiotherapy can refer on to secondary care services if indicated. This is the agreed spinal pathway

If patient re-presents to GP with persisting symptoms reassess red flags. See management section.

Differential Diagnosis

Consider the following differential diagnoses:

  • fracture – history of trauma or osteoporosis risk
  • atypical nerve root pain e.g. part of dermatome such as buttock, lateral hip or lateral lower leg only. Ipsilateral low back pain with spasm could also be atypical nerve root pathology.
  • pathology in an adjacent structure
  • malignancy: in the kidney or pelvis, e.g. prostate, ovaries, myeloma, metastases
  • infection:
    • lower urinary tract infection (UTI)
    • pyelonephritis or perinephric abscess
    • pelvic inflammatory disease (PID)
    • shingles and post-herpetic neuralgia
    • endocarditis
    • viral syndromes
  • Other:
    • renal calculi
    • hydronephrosis
    • aortic aneurysm
    • pancreatitis
    • endometriosis
    • ovarian cysts
    • dysmenorrhoea
    • coccydynia
    • iflammatory disorders
      • ankylosing spondylitis
      • polymyalgia rheumatica
  • metabolic bone disease
  • inflammatory back pain – see separate guidance
  • can refer directly to Rheumatology if symptoms and signs strongly suggestive of Axial Spondylarthropathy OR refer to Spinal Team if mixed picture.

NB: Common findings such as osteoarthritis or lumbar spondylosis are extremely common in asymptomatic people and may not be the source of pain.

Red Flags

The presence of 2 or more Red Flags significantly raises the likelihood of serious spinal pathology. Please refer to the STarT back Red Flags:

Send to ED if suspicion of

Spinal infection (history immunosupression, intravenous drug user (IVDU), fever, blood test sepsis, recent bacterial infection)

Refer URGENTLY to Spinal TEAM at RD&E via DRSS

  • in presence of deteriorating neurology (consider upper and lower motor neurone signs)
  • in cases of suspected cancer
  • dense foot drop (Oxford score below 3/5)
  • Worsening or bilateral nerve root pain after 4-6 weeks

Mark referrals clearly as URGENT and why.


Current NICE /UKSSB guidelines state MRI only for use in specialist clinic if it will change outcome. Patients should be told they may not need imaging if being referred to specialist clinic. There is a high level of incidental findings on scans e.g. disc degeneration therefore appropriate clinical interpretation is needed when feeding back MRI results is essential.

Refer for x-ray only in cases of suspected fracture:

  • sudden new back pain in women aged over 60
  • history of osteoporosis
  • history of steroid use
  • history of Ankylosing Spondylitis
  • other history suggests patient at risk of osteoporosis; (NICE guideline Osteoporosis - assessing the risk of fragility fracture)

If fracture is confirmed;

  • screen for myeloma or cancer and refer for DEXA scan
  • appropriate analgesia
  • consider referral to physiotherapy if function limited
  • refer to Spinal Pathway if pain not settling after 6-8 weeks or suspicion of serious underlying pathology

Bloods appropriate for suspicion of infection or cancer.


Self-care and self-management underpins all activities within this guideline, please encourage patients to engage with this approach throughout

Positive attitude to outcome – try to keep patient at work and maintain activity levels. Assess and address issues of distress or depression.

Encourage early activity – activity is not harmful and may help to reduce pain in many patients.

Avoid prolonged bed rest – at most one or two days in simple back pain.

Education and rehabilitation – emphasise self-management and reinforce positive attitudes to outcome.

Give patient supportive information on self-management (see Patient Information below).

MyHealth Devon

At each re-attendance:

  • review diagnosis and reconsider differential diagnosis.
  • retest neurology and range of movement/pain levels.
  • check compliance with advice.
  • check compliance/attendance with physiotherapy
  • consider referral to RD&E Spinal Team if severe pain, deteriorating symptoms including neurology, or significantly functionally impaired

Pharmacological interventions

  • Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs)
    • When prescribing oral NSAIDs, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment.
  • Consider opioids for managing acute nerve root pain.
    • In such circumstances, advise intermittent (not regular) use of opioid analgesia
  • Consider anti-neuropathic medications
  • Do not offer opioids for managing chronic low back pain
  • Do not offer paracetamol alone for managing low back pain

Guidance for healthcare professionals on drug driving


Referral Criteria

The agreed spinal pathway is:

  1. Initial GP management for 2 weeks
  2. Refer to physiotherapy if symptoms persisting or moderate/severe at 2 weeks
  3. Physiotherapy to refer to Spinal Team at 6 plus weeks if symptoms persisting
  4. GPs can refer direct to Spinal Team if patient meets criteria listed below or there are concerns re serious pathology

Refer To Physiotherapy:

  • If medium or high severity of symptoms after 2 weeks
  • If the patient has relapsed following previous successful treatment
  • Physiotherapy can refer on to RD&E Spinal Team directly if indicated

Refer To RD&E Spinal Team:

  • Patients with nerve root pain who have failed primary care conservative management
  • Patients with severe pain which is not responding to usual care at 4-6 weeks
  • Patients with deteriorating symptoms including neurology
  • Patients with significant functional impairment due to their severe nerve root pain

NHS Devon CCG - Commissioning policy: Spinal injections for sciatica

NHS Devon CCG - Commissioning policy: Radiofrequency denervation

Referral Instructions

Refer via e-Referral Service

  • Specialty: Orthopaedics
  • Clinic Type: Spinal
  • Service: DRSS-Eastern-Orthopaedics-Devon CCG- 15N

Referral Forms

DRSS Referral Form

Supporting Information

GP Information


NHS Devon CCG - Commissioning policy: Spinal injections for sciatica

NHS Devon CCG - Commissioning policy: Radiofrequency denervation

Supporting Information

MyHealth Devon

Start Back tool online Keele University website and GP advice on use of tool

Nice guidelines NG 59 - Low back pain and sciatica in over 16s: assessment and management

UKSSB (UK Spine Societies Board)

Opioids and driving - Guidance for healthcare professionals

Sheffield aches and pains - guidance for primary care.

Patient Information

MyHealth Devon

Recommended resources for patients and carers. NHS Devon CCG does not take responsibility for the content of third party information resources.

British Association Spinal Surgeons: patients area/ patient information

Low back pain, back pain management and understanding pain - Good videos to show to patients (see links below)

Arthritis Research UK - exercises and useful advice (see link below)

Arthritis Research UK - Patient information - What should I know about back pain?.

Drugs and the driving law

NICE - patient information

Sheffield back pain - patient information

The Pain toolkit – self-management website for people in chronic pain, wide ranging resource with details of the pain cycle, patient videos as well as guidance for health care professionals.


McCullough BJ, Johnson GR, Brook MI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012; 262: 941-946.

Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: February 2019


Home > Referral > Eastern locality > Musculoskeletal & Joint Disorders > Nerve Root Pain / Sciatica


  • First line
  • Second line
  • Specialist
  • Hospital