What criteria should I use to determine if a patient with sciatica requires referral for surgical evaluation?

Criteria for referral for surgical evaluation in patients with sciatica include:

• Emergency referral to spinal surgery if there is suspicion of cauda equina syndrome, acute spinal cord compression with new or progressive widespread neurological deficit, or progressive limb weakness including major motor radiculopathy.
• Urgent referral or urgent MRI (within 2 weeks) if there is suspicion of tumour or infection, or if red flag symptoms are present without neurological dysfunction.
• Referral for specialist assessment if there is severe or progressive motor deficit, such as foot drop.
• Consider specialist referral for spinal decompression if non-surgical treatment has not improved pain or function and radiological findings are consistent with sciatic symptoms.
• Referral for severe radicular pain persisting at 2–6 weeks depending on severity and improvement, or non-tolerable radicular pain at 6 weeks.

Body mass index, smoking status, or psychological distress should not influence the decision to refer for surgical opinion.

Epidural corticosteroid injections may be considered for acute and severe sciatica but are not a substitute for surgical referral when indicated.

These criteria are based on NICE guidelines and associated UK clinical pathways.

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