Chronic back pain is back pain that has lasted three months or longer. Sciatica is pain that travels from the lower back or buttock down the leg, usually because a nerve root in the spine is irritated or squeezed. Both are treated in steps. Education, exercise and a review of your medicines come first, then targeted nerve treatments, and neuromodulation only when simpler options have not given enough relief. At Poply Pain & Neuromodulation, consultant pain specialist Dr Kavita Poply works out the most likely source of your pain before recommending anything.
Why back pain becomes chronic
Most episodes of back pain settle within weeks. For some people they do not, and the reason is not always damage in the spine. Pain that lingers can involve irritated joints, discs or nerves, weakened deep stabilising muscles, and changes in how the nervous system processes pain signals, often called central sensitisation. Poor sleep, stress and fear of moving can keep the cycle going.
Scans help, but they do not tell the whole story. Many people with no back pain have disc bulges or joint wear on an MRI, and some people in severe pain have a scan that looks unremarkable. That is why we treat the person and the pattern of symptoms, not the picture alone.
Common sources of chronic back and leg pain
- Facet joints. Small joints at the back of the spine. Pain is usually felt in the back, sometimes into the buttock or thigh, and is often worse when leaning backwards or twisting.
- Discs. Wear or injury can cause central back pain, and a bulging disc can press on a nerve root and cause sciatica.
- Sacroiliac joint. Pain low on one side of the back, near the dimple above the buttock. It is often worse when standing up from a chair or climbing stairs.
- Nerve root irritation. Leg pain that feels burning, electric or shooting, sometimes with tingling or numbness below the knee.
- Deep stabilising muscles. When the multifidus muscles are not working well, the lower spine can feel unstable and ache with activity.
Symptoms of sciatica
Typical sciatica is pain from the lower back or buttock that runs down the back of the leg, often to below the knee, usually on one side. It can feel sharp, burning or like an electric shock, and may come with pins and needles, numbness or weakness in the leg or foot. Coughing, sneezing or sitting for a long time can make it worse. Back pain that only spreads to the buttock or thigh is often referred pain from a joint rather than true sciatica, although the two can overlap.
How we assess your pain
Your first consultation is a personalised evaluation. Dr Poply takes a detailed history, examines your back, hips and legs, reviews any scans and earlier treatments, and asks how the pain affects your sleep, mood, work and activity. Where it will change the decision, she may suggest further tests.
When the source of pain is unclear, a diagnostic block can help. A small amount of local anaesthetic is placed next to the nerves that supply a suspected painful joint. If your pain eases for the expected time, that tells us the joint is likely involved. NICE recommends that radiofrequency treatment for back pain is only considered after a positive response to this kind of block.
Treatment options: a step-by-step approach
Rehabilitation and self-management
NICE recommends exercise and psychological approaches such as CBT as part of a package for chronic low back pain, and manual therapy only alongside exercise. This is not a “just exercise” message. It reflects evidence that movement, pacing and confidence are central to recovery. We help you find a realistic starting point and can refer you to physiotherapy or pain psychology where needed.
Medicines
NICE advises against opioids for chronic back pain and chronic sciatica, and against gabapentinoids for low back pain. If you are already taking them, we can review whether they are helping and reduce them safely. For nerve-type pain, other medicines may be tried under specialist guidance.
Targeted injections
For radiating leg pain, image-guided nerve root or epidural injections can calm an inflamed nerve. NICE supports epidural injections mainly for acute and severe sciatica. For pain thought to come from a joint, diagnostic injections confirm the source before longer-lasting treatment is considered. Injections usually give temporary relief, so we use them to create a window for rehabilitation or to guide the next step, not as a stand-alone answer.
Radiofrequency ablation
Radiofrequency ablation uses heat from a fine needle to interrupt the small nerves that carry pain from a joint. NICE suggests considering it for chronic low back pain when non-surgical treatment has not worked, the pain is mostly localised and rated 5 out of 10 or more, and a diagnostic block has been positive. Dr Poply co-authored a randomised, sham-controlled trial of radiofrequency treatment for sacroiliac joint pain, published in Pain Physician in 2018.
Neuromodulation
Neuromodulation changes how nerves send pain signals, using small electrical pulses delivered through thin leads placed near the spine or a nerve. Three forms are used for back and leg pain:
- Spinal cord stimulation (SCS). Leads sit in the space around the spinal cord and connect to a small pulse generator under the skin. It is mainly used for persistent nerve-type leg pain. NICE recommends SCS for adults with chronic neuropathic pain lasting at least 6 months despite conventional medical management, once a trial of stimulation has been successful and a specialist team has assessed you.
- Dorsal root ganglion (DRG) stimulation. The lead is placed near the cluster of nerve cells that serves a specific area, which suits pain in a well-defined region.
- Multifidus stimulation. For one type of mechanical back pain linked to poor control of the multifidus muscle, a device near a nerve at the L2 level makes the muscle contract. In the randomised ReActiv8-B trial of 204 people, the proportion whose pain improved by 30% or more at four months was 56% with active stimulation and 47% with sham stimulation, so the pain result at that point was not clear-cut. A later analysis reported better disability, quality of life and satisfaction with active treatment, and follow-up of treated patients reports lasting improvement. It is a developing option, and we talk through its limits openly.
Dr Poply co-authored the HIDENS study, published in Pain Practice in 2022, which followed 20 people with persistent lumbar radiculopathy and no previous spinal surgery after high-dose spinal cord stimulation. It was small and had no control group, so it cannot prove effectiveness, but it reflects direct experience with this treatment.
Is spinal cord stimulation right for you?
We look at whether your situation fits. Suitable people usually have:
- Pain for at least six months that has not improved enough with rehabilitation, medicines and appropriate injections
- a nerve component to the pain, especially leg pain
- no spinal problem that needs surgery instead
- realistic expectations, after an assessment that may include a pain psychologist
- a successful trial period, in which temporary leads are used first to test the effect before any permanent device is fitted.
Benefits and risks
In the PROCESS trial, which followed people with persistent leg pain after spinal surgery, 48% of those given SCS plus medical management had at least 50% leg pain relief at six months, compared with 9% with medical management alone. Not everyone benefits, and the effect can fade over time.
About a third of implanted patients in that trial had a device-related complication, most often a lead moving from its position. Other risks include infection, pain at the generator site, lead breakage and, rarely, nerve injury or bleeding around the spinal cord. Some problems need a minor further procedure. The system can be removed if it is not helping, and the trial phase lets you test the treatment before committing.
What to expect at your consultation
Bring your scan reports or images, clinic letters and a list of current medicines.
We talk through your history, what you have tried, and what you most want to change.
After examination, Dr Poply explains the likely source of your pain and which options are suitable, with the benefits and risks of each.
You are not expected to decide on the day. A plan is agreed at a pace that suits you.
Poply Pain & Neuromodulation welcomes self-funded patients and many private medical insurance patients (confirm insurers).
Why choose Dr Poply for back pain and sciatica
Dr Kavita Poply is a Consultant in Pain Medicine and Neuromodulation at St Bartholomew’s Hospital, London, and a Reader at Queen Mary University of London. She holds Fellowships of the Royal College of Anaesthetists and its Faculty of Pain Medicine, and a PhD from Queen Mary University of London for research in neuromodulation. She leads the postgraduate certificate in Neuromodulation and Pain Management at QMUL. Her treatment approach escalates step by step, from simple injections to radiofrequency and then to neurostimulation, in line with NICE guidance.
Frequently asked questions
Q.1 What is the difference between chronic back pain and sciatica?
Ans. Chronic back pain is pain in the back lasting three months or more. Sciatica is nerve pain that travels down the leg, usually from an irritated nerve root in the lower spine. You can have either on its own, or both together. The distinction matters because treatment differs: nerve-related leg pain may respond to targeted nerve treatments, while joint-related back pain may need a different approach.
Q.2 How long does sciatica last, and when should I see a specialist?
Ans. Many people with sciatica improve over weeks to a few months with simple measures. Ask your GP about specialist assessment if your leg pain is severe, getting worse, or has not improved after several weeks of treatment. Seek emergency help at once if you develop bladder or bowel problems, saddle numbness or weakness in both legs.
Q.3 Does an MRI scan show what is causing my back pain?
Ans. Not always. Many people without pain have disc bulges or joint wear on MRI, and some people with significant pain have a scan that looks fairly normal. An MRI is most useful when read together with your symptoms and examination. Dr Poply reviews your scans alongside your history rather than relying on the report alone.
Q.4 Is spinal cord stimulation for back pain available on the NHS?
Ans. NICE recommends spinal cord stimulation for adults with chronic neuropathic pain that has lasted at least 6 months despite conventional treatment, after a multidisciplinary assessment and a successful trial. NHS access depends on meeting these criteria and on local commissioning. A private consultation gives you direct access to specialist assessment and an explanation of whether you are likely to be suitable.
Q.5 Can chronic back pain be treated without surgery?
Ans. Yes. Most chronic back pain is managed without surgery. NICE advises against spinal fusion for non-specific low back pain outside clinical trials. Exercise, psychological support, targeted injections, radiofrequency treatment and, for selected people, neuromodulation are the main non-surgical options. Surgery is considered when there is a clear structural problem, such as significant nerve compression, that fits your symptoms.