Lumbar Radiculopathy Treatment

Original Editor - Matt Huey

Top Contributors - Matt Huey and Jess Bell  

Introduction

Lumbar radiculopathy is recognised as a pain that radiates down the leg from the lumbar spine. It's commonly caused by a compression of the nerve root, which leads to symptoms such as altered sensation, decreased reflexes, and weakness, along with descriptions of pain as sharp, shocks, numbness and / or tingling, etc. It affects approximately 3-5% of the population, with men often experiencing it in their 40s while women experience it in their 50s and 60s.

There is controversy over what is the correct or optimal treatment for lumbar radiculopathy. Treatments include invasive procedures (surgery and injections), non-invasive procedures (education, manual therapy, exercise) and pharmacological management (non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids). Often, the appropriate course of treatment may include a combination of interventions.

Assessment

The assessment of a lumbar radiculopathy aims to determine if the person is appropriate for treatment. The assessment should include a subjective evaluation, which includes the history, aggravating/easing factors, and location of symptoms, as well as an objective assessment.

Objective measures can include:

• myotome testing (manual muscle testing (MMT))
• sensation testing
• deep tendon reflex testing
• neurodynamics
• lumbar range of motion
• upper motor neuron testing such as Hoffmann's sign, and ankle clonus

These test should not be performed in isolation but rather in combination to improve the diagnosis. You may also utilise these tests to show improvement or regression over time.

For more information on the objective assessment, please see: Lumbar Radiculopathy Assessment.

Red Flags

Screening for red flags should be part of your assessment. With lumbar radiculopathy, there is a risk of a serious pathology, such as caudia equina syndrome, cancer, or fractures. A few things to keep in mind about the prevalence of red flags. They will often be more prevalent in certain areas of medicine. A spinal surgeon will see more red flags than a physiotherapist. Even with physicians, there are differences. Emergency room physicians will see more cases of serious spinal pathologies than primary care physicians.

Be aware that a single red flag symptom may not be due to a serious spinal pathology. Additionally, some symptoms have been found to need further investigation, including:

• recent trauma (especially over 50 years of age) raises the chance of vertebral fracture
• history of cancer
• recent history of infection
• changes / loss of bladder and / or bowel control
• pain that wakes the patient from sleep (please note this does have a high false positive rate)

A framework has been developed to help clinicians when screening for red flags. This framework encourages clinicians to not simply rely on one red flag, but rather to consider the context of the patient and the context of the red flag/s, including symptom progression and co-morbidities. Based upon the findings, clinicians consider the level of concern and take appropriate action:

• Begin therapy (Can change the treatment if there is a change in the red flag symptoms)
• Begin a trial of therapy with watchful waiting (Same as above but monitor progress closely)
• Urgent referral (Do not begin therapy and either investigate further or refer to specialist)
• Emergency referral (Do not begin therapy and refer for emergency care)

This framework is described in detail here: An Introduction to Red Flags in Serious Pathology.

Interventions

One aspect that must be kept in mind when managing lumbar radiculopathy is that treatment is often not isolated to one specific intervention. Most of the evidence presented in the following sections considers interventions that are utilised in conjunction with other interventions. Each one of the following treatments can be used alongside another treatment.

Manual Therapy

Manual therapy techniques can include a number of different hands on approaches. Commonly used manual therapy techniques utilised with patients experiencing lumbar radiculopathy include mobilisation of the lumbar spine, mobilisation of the nerves, or manipulation. Aspects to keep in mind when deciding to use any hands on technique are contraindications, along with the skill level of the provider and comfort level of the patient. There are patients whose pain symptoms are very irritable and manual therapy techniques may intensify the pain symptoms.

Mobilisation of the Lumbar Spine

Spinal mobilisations are passive movements of a spinal segment that follow a grading scale (I-IV). The goal of mobilisations can be to decrease pain symptoms and improve spinal mobility. There is evidence to show that the use of spinal mobilisation can be beneficial in the treatment of lumbar radiculopathy. Several studies have found the use of spinal mobilisations with leg movement show some benefit in decreasing pain. Do keep in mind that in these studies, mobilisations were used in alongside other treatments, including exercises and modalities. This suggests that mobilisations can make up part of a possible treatment.

Mobilisation of the Nerve

Mobilisation of the sciatic or femoral nerve is either a tensioning or gliding of the nerve. The technique is similar to the testing procedures of the straight leg raise test, slump test, or femoral nerve test. There is evidence that mobilising the nerve can help to decrease pain and improve function.

These techniques can be beneficial for patients experiencing acute symptoms to assist in decreasing sensitivity. They can also be utilised with individuals with a possible entrapment.

Manipulation of the Lumbar spine

High velocity, low amplitude (HVLA) or manipulation techniques are quick, passive movements applied to either a specific level of the spine or as a general technique. There is evidence to show that manipulations can be beneficial for individuals with lumbar radiculopathy. Additionally, there is evidence to show that the use of manipulations can decrease the prescription of benzodiazepines and chance of discectomy. The evidence concludes that manipulation should be used as an adjunct with other treatments, including exercise.

Exercise

It has been found that exercise can be included as part of a patient's treatment plan. However, in research, exercise as a management strategy is often just expressed as "exercise" without much additional information given. The two most commonly researched areas of exercise with lumbar radiculopathy are stabilisation exercises and extension-based exercises.

Stabilisation exercises aim to improve the motor control of the spine stabilisers. It is believed that if there is a disruption in the motor control in the spine, the use of stabilisation activities restores this control and decreases pain. Most research utilises stabilisation exercises along with other interventions, such as spinal manipulation and extension movements such as cat-camel or a seated lumbar extension.

Repeated Movements

The use of repeated movements is a hallmark of the McKenzie Method or MDT (Mechanical Diagnosis and Therapy). When utilising repeated movements, the goal is to determine a directional preference, which is indicated by the centralisation of the symptoms. It has been found that if a patient is able to centralise their symptoms, they improve their outcomes. While there is often a focus on extension-based movements, and there are studies demonstrating that repeated extensions can help people with lumbar radiculopathy symptoms, the proper utilisation of repeated movements may involve movements in the sagittal plane (flexion / extension), frontal plane (lateral), or a combination of movements.

Education

Education is a staple of helping people with not only lumbar radiculopathy, but also with rehabilitation any disorder or condition. Education has been included in clinical guidelines about treating back pain and lumbar radiculopathy. Within research, education is often a broad topic that may include things such as performing healthy habits such as diet and sleep, lifting mechanics, posture, and overall general activity. There is evidence that has broken this down into what patients have expressed what they want in terms of information on low back pain, which can include lumbar radiculopathy. It was found that patients want a definite diagnosis to the cause of their symptoms along with a personalized management strategy. They also wanted consistent information on the nature of low back pain along with management strategies that were pharmacological and non-pharmacological. They wanted this presented to them in a manner that was appropriate for their age, lifestyle, and occupational status that was in an understandable language.

Modalities

Modalities are commonly utilized interventions with rehabilitation of many conditions. For lumbar radiculopathy, the use of mechanical traction and electrical stimulation, such as TENS, are two of the most common. In looking at current evidence, modalities are not as effective as manual therapy or exercise but some evidence for the short term. Often with research, traction or electrical stimulation is considered "physical therapy" instead of exercise or manual therapy approaches. The use of modalities does seem to show some benefit when used in conjunction with additional interventions.

Medication

The prescription of medications is limited within the physiotherapy profession, however, this may be a conversation to have with patients. There is mixed evidence for the use of medication in the treatment of lumbar radiculopathy. The most often prescribed medication is an non-steroidal anti-inflammatory drug (NSAID). There is some evidence that it could help in the short term, however limited benefit in the long term. Anticonvulsants (such as gabapentin) are another medication that can be prescribed specifically due to the radicular symptoms. There is evidence that these are largely ineffective as well for the treatment of lumbar radiculopathy. Overall not been recommended in treatment guidelines that medications are effective.

Epidural Injection

Epidural injections are another area that is outside the scope of some providers. It can be a possible intervention for people who fail conservative management. There is mixed evidence for the utilization of epidural injections . In the evidence that supports epidural injections, it does not lay out things such as is it more effective at certain pain levels or at certain points during the course of dealing with radicular symptoms. Something to keep in mind as well is that a person of a lower socioeconomic status may experience more relief with the use of an epidural.

Surgery

Surgery can be considered the final option for patients who do not do well with conservative treatment. The outcomes on surgical and non-surgical are similar over a 2 year time period with surgical outcomes being slightly, but not significantly, better. Surgery should be withheld for only those patients with the most severe symptoms or that are showing red flag symptoms.

Rehab after a lumbar surgery is also recommended which should include education. It's also beneficial to provide education prior to surgery as well since it has been found to aid in decreasing fear of movement and improved function after surgery.