Sciatica

Symptoms depend on the root level involved:

• L4 root (L3–L4 disc): Pain along the anterior thigh and medial leg; sensory loss over the medial shin and foot; weakness of knee extension and dorsiflexion; reduced patellar reflex.
• L5 root (L4–L5 disc): Pain along the lateral leg and dorsum of the foot; sensory loss over the lateral calf and great toe; weakness of extensor hallucis longus and ankle dorsiflexion; medial hamstring reflex may be reduced.
• S1 root (L5–S1 disc): Pain along the posterior thigh, calf, and heel; sensory loss over the lateral foot and little toe; weakness of plantarflexion and toe push-off; reduced or absent Achilles reflex.
• Bilateral leg symptoms or progressive weakness in both legs
• Bowel or bladder dysfunction (retention, incontinence) — possible cauda equina syndrome
• Saddle anesthesia (numbness in the perineum)
• Fever with back pain (infection)
• History of malignancy with new back/leg pain

> Call us at (301) 515-0900 — same-day appointments available at our Bethesda and Germantown locations. Cauda equina syndrome is a surgical emergency — seek immediate care if bladder or bowel dysfunction develops.

Clinical examination: The straight leg raise (SLR) test is the single most important provocative test for lumbar radiculopathy. With the patient supine, passively raising the extended leg to 30–70° reproduces concordant radiating leg pain below the knee — a positive SLR is both sensitive (~80%) and, when positive at low angles, highly specific for L4–L5 or L5–S1 root tension. The crossed SLR (raising the contralateral leg reproduces ipsilateral leg pain) is highly specific for large disc herniations.

Neurological examination documents motor strength, dermatomal sensory changes, and deep tendon reflexes to identify the involved root level. Inconsistencies between examination and dermatomal distributions suggest referred pain rather than true radiculopathy.

Imaging:

• MRI of the lumbar spine is the primary diagnostic study when radiculopathy persists beyond 4–6 weeks or when neurological deficit is identified. MRI confirms disc herniation, foraminal stenosis, or other structural cause.
• Plain radiographs assess alignment and disc height.
• EMG/nerve conduction studies are reserved for complex cases where the level is unclear, for ruling out peripheral nerve entrapment, or when significant motor involvement requires prognostic information.

Most patients with sciatica from disc herniation recover fully with non-operative care. Recovery is often gradual — leg symptoms typically resolve before back pain completely abates. Patients should expect 6–12 weeks of treatment before assessing the need for further intervention. Recurrence is possible with subsequent disc problems; maintaining core strength, ideal body weight, and proper lifting mechanics reduces recurrence risk.