History Taking · Foundation · Surgery

Back Pain with Leg Pain and Weakness

Practise this PLAB 2 history taking station on Lumbar Radiculopathy. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the GP surgery. Mr Jamie Park, a 54-year-old man, has presented with lower back pain radiating to his leg with difficulty walking. He is concerned about progressive weakness. Please take a history assessing for intervertebral disc prolapse and neurological deficit, excluding cauda equina syndrome.

Background notes: PMH: Occasional non-specific back pain (minor), Appendicectomy age 32, History of indigestion

What this station tests

  • Distinguishing radiculopathy from cauda equina: single nerve root distribution versus bilateral symptoms with bladder/bowel involvement
  • Dermatomal localisation: L5 (lateral calf, dorsum of foot, heel walking difficulty) versus S1 (posterior calf, sole, tiptoe difficulty)
  • Progressive motor deficit as an indication for urgent MRI: stable radiculopathy can wait, progressive cannot
  • Neuropathic pain agents: amitriptyline or gabapentin for nerve-related leg pain alongside standard analgesia
  • Cauda equina safety netting as mandatory in every back pain with radiculopathy consultation

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Back pain with leg radiation and progressive weakness requires careful red flag screening to distinguish radiculopathy (which can be managed conservatively initially) from cauda equina syndrome (which is a neurosurgical emergency). Mr Park is 54, presenting with 5 weeks of back pain now radiating down his right leg with increasing weakness. Open with: 'Mr Park, the leg weakness is concerning. I need to ask you some specific questions to determine how urgently we need to act.'

Core approach

Characterise the radiculopathy. Back pain started 5 weeks ago after heavy lifting, now radiating from right buttock down the posterior thigh and lateral calf (L5/S1 distribution). The leg pain is worse than the back pain (a feature of true radiculopathy). He has numbness on the outer calf and top of foot. Right foot is slightly weak (difficulty walking on heels suggests L5, difficulty on tiptoes suggests S1). This is a single nerve root pattern.

Screen for cauda equina urgently. Saddle anaesthesia: any numbness around buttocks, perineum, or genitals? No. Bladder function: any difficulty starting, stopping, or controlling urine? No. Bowel function: any incontinence or loss of control? No. Bilateral leg symptoms? No (right only). These negatives are critically important and must be documented.

Assess severity of the motor deficit. Is the weakness stable or progressing? He says it has been gradually worsening over 2 weeks. Progressive motor deficit is a relative indication for urgent MRI and surgical opinion, even without cauda equina features. Can he walk? Yes, with a limp. Can he stand on his right heel? With difficulty. This suggests moderate L5 weakness.

Closing and safety netting

This presentation, progressive radiculopathy with increasing motor weakness, warrants urgent MRI and consideration of surgical opinion. 'Mr Park, the pain going down your leg and the weakness in your foot suggest a disc in your spine is pressing on a nerve. Because the weakness is getting worse, we need an MRI scan of your spine to see exactly what is happening.'

Arrange urgent MRI (within 2 weeks given progressive weakness). Refer to spinal surgery or neurosurgery. Analgesia: neuropathic pain agents (amitriptyline or gabapentin) alongside regular paracetamol and NSAIDs. Avoid opioids if possible. Physiotherapy once acute phase settles.

Cauda equina safety netting is essential: 'If you develop numbness around your bottom, any difficulty with your bladder or bowels, or the weakness suddenly gets much worse, go to A&E immediately and tell them you may have cauda equina syndrome. This would be an emergency.' Follow-up after MRI.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for lumbar radiculopathy. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Radiculopathy pattern identified with dermatomal localisation. Cauda equina screening documented. Progressive weakness timeline established. Motor deficit graded. Red flags excluded.

Costs marks: Not localising the dermatome. Not screening cauda equina. Not identifying progressive weakness. Incomplete red flag screening.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Urgent MRI arranged (progressive weakness). Surgical referral. Neuropathic pain agents prescribed. Cauda equina safety netting. Physiotherapy planned.

Costs marks: Conservative management without imaging for progressive deficit. No neuropathic agents. No cauda equina safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining disc prolapse in lay terms. Addressing his fear of surgery. Providing clear cauda equina warning he can act on. Acknowledging work impact.

Costs marks: Using jargon. Not addressing surgery concern. Vague safety netting. Ignoring work impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not screening for cauda equina. Every patient with back pain and leg symptoms must be asked about saddle anaesthesia and bladder/bowel function. Candidates who assess the radiculopathy without these questions risk missing an emergency.
  2. Not recognising progressive weakness as an indication for urgent MRI. Stable radiculopathy can be managed conservatively for 6 to 8 weeks. Progressive motor deficit over 2 weeks needs urgent imaging. Candidates who manage this conservatively without imaging delay potentially necessary surgery.
  3. Not prescribing neuropathic pain agents. Standard analgesics (paracetamol, NSAIDs) are inadequate for radicular pain. Amitriptyline or gabapentin address the neuropathic component. Candidates who prescribe only paracetamol and ibuprofen provide suboptimal pain management.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the lumbar radiculopathy history in this PLAB 2 station?

Back pain with leg radiation and progressive weakness requires careful red flag screening to distinguish radiculopathy (which can be managed conservatively initially) from cauda equina syndrome (which is a neurosurgical emergency). Mr Park is 54, presenting with 5 weeks of back pain now radiating down his right leg with increasing weakness.

What are examiners marking in this lumbar radiculopathy station?

Marks are won for: Radiculopathy pattern identified with dermatomal localisation. Cauda equina screening documented. Progressive weakness timeline established. Motor deficit graded. Red flags excluded. Marks are lost for: Not localising the dermatome. Not screening cauda equina. Not identifying progressive weakness. Incomplete red flag screening.

What is the most common mistake candidates make in this lumbar radiculopathy station?

Not screening for cauda equina. Every patient with back pain and leg symptoms must be asked about saddle anaesthesia and bladder/bowel function. Candidates who assess the radiculopathy without these questions risk missing an emergency.

How do I prepare for this station if I have not managed lumbar radiculopathy in clinical practice?

This station rewards process over personal experience. The skill being assessed: Dermatomal localisation: L5 (lateral calf, dorsum of foot, heel walking difficulty) versus S1 (posterior calf, sole, tiptoe difficulty). The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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