It has been 3 nights of pain from the buttock to the foot, and by 1am they are reading about discs and operations. Most of that reading is misery, not danger. The phrase they should actually know is sciatica red flags, because a small number of these presentations are not a disc story at all. They are a reason to call an ambulance rather than book a GP.
Most pain down the leg is miserable and still not an emergency. Saddle numbness, new incontinence, or rapidly worsening weakness in a leg is an ambulance. I would rather send you in once too often than miss that pattern. A disc on an old scan does not decide this. The new symptoms do.
Chest pain, signs of a stroke, severe breathlessness, heavy bleeding, a severe allergic reaction or symptoms of sepsis need 999 or A&E immediately. A clinic appointment is the wrong door for those.
What are sciatica red flags?
The short version is this. Pain in a nerve distribution down the leg is common. Pressure on the nerves that supply the bladder, the bowel and the saddle area is not common, and it does not wait for a Friday appointment. If you cannot feel the saddle when you wipe, if you have new bowel or bladder loss, or if a foot is getting weaker by the hour, call 999.
It is worth saying plainly. Google will show you the worst case on the first screen. That does not make your Tuesday an emergency. It also does not make the worst case imaginary. The job is to tell those 2 apart with questions and an examination, not with a photograph of last year’s scan.
If those warning features are absent, be seen at Palmers Green for a proper exam. If they are present, do not come here first.
What does the examination actually involve?
What I look at in clinic is the story of the last 48 hours, not the story of the last 10 years. When it started. Whether a cough or a sneeze shoots it down the leg. Whether you can sit, walk, or put a sock on. Whether the pain is one leg or both. Whether anything is actually weaker, or just too sore to use.
Then the questions people find awkward, asked without apology. Can you feel toilet paper on both sides. Have you wet yourself, or been unable to pass urine, or lost control of the bowel, as a new thing. Has sex gone numb. Has the weakness come on over hours rather than over weeks. I ask them every time, even when the person looks well and arrived on the bus. The piece most people miss is that pride is how this gets delayed.
Examination is shoes off, watching you walk, watching you stand on heels and toes, checking power at the hip, knee, ankle and big toe, checking the knee and ankle jerks, and checking sensation along the foot and the saddle. Straight leg raise if it adds something. I do not need a scan in the room to know whether this is the ordinary miserable sort or the sort that leaves the building in an ambulance.
An old scan that showed a disc is history. Discs are common on films in people who have no pain at all. NICE is clear that imaging does not drive the first look in ordinary back pain with leg radiation. The new neurology does. If power is dropping, if the saddle is numb, if the bladder has changed, the destination is hospital, not a request form for another picture.
If the warning features are absent, the plan is usually time, movement within what you can bear, and pain relief you can buy in a pharmacy, with a clear window to come back. I often say 7 to 14 days if it is stable, and sooner if it is not. Staying in bed for a week is how backs get worse, not better. With Dr Ahmed’s input on the rehabilitation side, we can talk about what you can still do this week without pretending we have a trick that ends sciatica on a Thursday.
I cannot promise the pain will settle on a date, or that you will avoid a scan for ever, or that a specialist will see you next week. You get an examination and an honest next step. You do not get a date when the pain will end.
When should I come in sooner?
Some of this is 999. Some of it is the same day clinic. The difference is worth having in your head at 11pm.
- New numbness between the legs, around the back passage, or in the saddle when you wipe.
- New incontinence of urine or faeces, or being unable to pass urine.
- Weakness in a leg that is getting worse over hours, a foot that is slapping, or both legs involved.
- Back pain with fever, or in a person who uses injected drugs, or after a recent infection, because the disc is not the only structure in there.
- Back pain after a fall in someone with osteoporosis, cancer, or steroid treatment over a long time.
- Unexplained weight loss, night pain that will not settle, or a history of cancer and a new, unrelenting back.
When this comes up in consultation I would rather send you in once too often. That is not drama. It is how you sleep afterwards.
How do we see this in Palmers Green?
You are examined face to face at 466 Green Lanes, or at home if you cannot travel and this is not an ambulance. A 30 minute GP appointment is £100. A home visit is £250 in the day and £450 at night, each up to an hour. Same day is subject to the diary. If the diary is full and the warning features are present, A&E is the plan, not a waiting list.
A referral letter is £50 where a specialist look is actually indicated after assessment. We do not write one to skip the examination. Read the same day private GP page if you need to be seen today, or the home visiting GP page if the house is safer and this is not 999.
If those warning features are absent, come in for a proper exam rather than lying on the floor waiting for an MRI to make the decision. If they are present, call 999.
Get the back and the leg examined, and the awkward questions asked. Read our fees page, or call 020 8882 8088. Home visits £250 day, £450 night, published in full. In an emergency call 999. Subject to availability.
Written by Dr Mitesh Parmar, MBBS MRCGP, GP and founder of Clinique Alpa, 466 Green Lanes, Palmers Green, London N13 5PA. This article is general information, not personal medical advice. In an emergency call 999. For NHS advice call 111 or visit nhs.uk.