Lumbar Radiculopathy Treatment

Original Editor - Matt Huey

Top Contributors - Matt Huey and Jess Bell  

Introduction[edit | edit source]

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.[1]

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[edit | edit source]

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:

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[edit | edit source]

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.[2]

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[3]:

  • 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.[4] 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[4]:

  • 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[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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.[5] [6][7][8] 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[edit | edit source]

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.[9]

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[edit | edit source]

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.[10] Additionally, there is evidence to show that the use of manipulations can decrease the prescription of benzodiazepines[11] and chance of discectomy.[12] The evidence concludes that manipulation should be used as an adjunct with other treatments, including exercise.

Exercise[edit | edit source]

It has been found that exercise can be included as part of a patient's treatment plan.[13] 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.[14][15][16]

Repeated Movements[edit | edit source]

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.[17] 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,[6] the proper utilisation of repeated movements may involve movements in the sagittal plane (flexion / extension), frontal plane (lateral), or a combination of movements.

Education[edit | edit source]

Education is a staple of treatment for many conditions, including lumbar radiculopathy.[13] Education has been included in clinical guidelines for treating back pain and lumbar radiculopathy.[18] In research, education is often a broad topic that may cover different aspects, such as maintaining a healthy lifestyle (e.g. diet and sleep), lifting mechanics, posture, and overall general activity. A systematic review by Lim et al.[19] explored what patients want in terms of information on low back pain, which can include lumbar radiculopathy. They found that patients want:[19]

  • a definite diagnosis to the cause of their symptoms (which may contribute "to expectations for and overuse of imaging"[19])
  • a personalised management strategy, included pharmacological and non-pharmacological management strategies
  • consistent information on the nature of low back pain along with management strategies that were pharmacological and non-pharmacological

Moreover, this information should be presented in a manner that was appropriate for their age, lifestyle, and occupational status, and the language and terminology should be understandable.[19]

Modalities[edit | edit source]

Modalities are commonly utilised in the rehabilitation of many conditions. Two of the most common modalities for lumbar radiculopathy are mechanical traction and electrical stimulation (e.g. transcutaneous electrical nerve stimulation (TENS)). Current evidence suggests that modalities are not as effective as manual therapy or exercise, but there is some evidence for short-term benefits.[20][21] It is important to note that in the literature, traction or electrical stimulation are often considered "physical therapy / physiotherapy" instead of exercise or manual therapy approaches.[22] Using modalities in conjunction with additional interventions appears to have some benefit.[23][24]

Medication[edit | edit source]

There is mixed evidence for the use of medication in the treatment of lumbar radiculopathy.[13] The most often prescribed medications are non-steroidal anti-inflammatory drugs (NSAID).[1] There is some evidence that NSAIDs could help in the short term,[25] but have a limited benefit in the long term. Anticonvulsants (such as gabapentin) are another medication that can be prescribed specifically for radicular symptoms. There is evidence that these are largely ineffective for the treatment of lumbar radiculopathy.[26] Recent guidelines recommend against the use of NSAIDs and other opiods in the treatment of lumbar radiculopathy.[27]

Epidural Injection[edit | edit source]

An epidural injection can be a possible intervention for people who do not improve with conservative management.[1] There is mixed evidence for the utilisation of epidural injections.[13] [18][28] It has been found that socioeconomic status has an impact on the level of pain alleviation from an epidural injection. Jayabalan et al. found that "Lower socioeconomic status was independently associated with higher pain alleviation after controlling for other potentially influential demographics."[29]

Surgery[edit | edit source]

Surgery can be considered the final option for patients who do not improve with conservative treatment.[13] The outcomes associated with surgical and non-surgical interventions are similar over a two year period; surgical outcomes are slightly, but not significantly, better.[1] Surgery should be considered for those patients with the most severe symptoms or who are showing red flag symptoms.

Rehabilitation, including patient education, is recommended for individuals having lumbar surgery.[30] It is also beneficial to provide education prior to surgery. Pre-operative education has been found to help decrease fear of movement and improve function after surgery.[31]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. Cureus. 2019;11(10).
  2. ↑ Galliker G, Scherer DE, Trippolini MA, Rasmussen-Barr E, LoMartire R, Wertli MM. Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags. The American journal of medicine. 2020;133(1):60-72.
  3. ↑ Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red flags for low back pain are not always really red: a prospective evaluation of the clinical utility of commonly used screening questions for low back pain. The Journal of bone and joint surgery. American volume. 2018;100(5):368-74.
  4. ↑ 4.0 4.1 Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy. 2020;50(7):350–72.
  5. ↑ Kuligowski T, Skrzek A, Cieślik B. Manual therapy in cervical and lumbar radiculopathy: a systematic review of the literature. International journal of environmental research and public health. 2021;18(11):6176.
  6. ↑ 6.0 6.1 Ashraf B, Ahmad S, Ashraf K, Kanwal, S, Ashraf, S, Khan N, et al. Effectiveness of spinal mobilization with leg movement versus McKenzie back extension exercises in lumbar radiculopathy. Pakistan J. Med. Heal. Sci. 2021;15(5):1436-40.
  7. ↑ Danazumi M, Bello B, Yakasai A, Kaka B. Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial. Journal of Osteopathic Medicine. 2021;121(4):391-400.
  8. ↑ Bello B, Danazumi MS, Kaka B. Comparative Effectiveness of 2 Manual Therapy Techniques in the Management of Lumbar Radiculopathy: A Randomized Clinical Trial. Journal of chiropractic medicine. 2019;18(4):253–60.
  9. ↑ Lin L-H, Lin T-Y, Chang K-V, Wu W-T, Özçakar L. Neural mobilization for reducing pain and disability in patients with lumbar radiculopathy: A systematic review and meta-analysis. Life. 2023; 13(12):2255.
  10. ↑ Ghasabmahaleh SH, Rezasoltani Z, Dadarkhah A, Hamidipanah S, Mofrad RK, Najafi S. Spinal manipulation for subacute and chronic lumbar radiculopathy: a randomized controlled Trial. The American Journal of Medicine. 2021;134(1):135-41.
  11. ↑ Trager RJ, Cupler ZA, DeLano KJ, Perez JA, Dusek JA. Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA. BMJ Open. 2022 Jun 13;12(6):e058769.
  12. ↑ Trager RJ, Daniels CJ, Perez JA, et al Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States’ data BMJ Open 2022;12:e068262. doi: 10.1136/bmjopen-2022-068262
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Khorami AK, Oliveira CB, Maher CG, Bindels PJ, Machado GC, Pinto RZ, et al. Recommendations for diagnosis and treatment of lumbosacral radicular pain: a systematic review of clinical practice guidelines. Journal of Clinical Medicine. 2021;10(11):2482.
  14. ↑ Kostadinović S, Milovanović N, Jovanović J, Tomašević-Todorović S. Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation. 2020;33(6):897-907.
  15. ↑ Golonka W, Raschka C, Harandi VM, Domokos B, Alfredson H, Alfen FM, Spang C. Isolated lumbar extension resistance exercise in limited range of motion for patients with lumbar radiculopathy and disk herniation—Clinical outcome and influencing factors. Journal of Clinical Medicine, 10(11), 2430.
  16. ↑ Danazumi, Musa Sani1,2,. Physiotherapy Management of Lumbar Disc Herniation with Radiculopathy: A Narrative Review. Nigerian Journal of Experimental and Clinical Biosciences 7(2):p 93-100, Jul–Dec 2019. | DOI: 10.4103/njecp.njecp_30_19
  17. ↑ Albert, H. B., Hauge, E., & Manniche, C. (2012). Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(4), 630–636. https://doi.org/10.1007/s00586-011-2018-9
  18. ↑ 18.0 18.1 Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2018;27(1):60-75.
  19. ↑ 19.0 19.1 19.2 19.3 Lim YZ, Chou L, Au RT, Seneviwickrama KMD, Cicuttini FM, Briggs AM, et al. People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. Journal of physiotherapy. 2019;65(3):124-35.
  20. ↑ Vanti C, Saccardo K, Panizzolo A, Turone L, Guccione AA, Pillastrini P. The effects of the addition of mechanical traction to physical therapy on low back pain? A systematic review with meta-analysis. Acta orthopaedica et traumatologica turcica. 2023;57(1):3-16.
  21. ↑ Amjad F, Mohseni-Bandpei MA, Gilani SA, Ahmad A, Hanif A. Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial. BMC musculoskeletal disorders. 2022;23(1):255.
  22. ↑ Kolu E, Buyukavci R, Akturk S, Eren F, Ersoy Y. Comparison of high-intensity laser therapy and combination of transcutaneous nerve stimulation and ultrasound treatment in patients with chronic lumbar radiculopathy: A randomized single-blind study. Pakistan journal of medical sciences. 2018;34(3):530-34.
  23. ↑ Sanjana M, Yatish R. Comparative study on the Mckenzie technique with tens versus neural mobilization with tens in chronic low back pain with radiculopathy. International Journal of Physical Education, Sports and Health. 2021;8(1):08-13.
  24. ↑ Divyasree, S., Kumaresan, A., & Vishnuram, S. (2023). Effect of Mckenzie lumbar extension exercise with TENS on lumbar radiculopathy. Biomedicine, 43(3), 1032-1035.
  25. ↑ Van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for acute low back pain. The Cochrane database of systematic reviews. 2020;4(4):CD013581.
  26. ↑ Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. Cmaj. 2018;190(26):E786-E793.
  27. ↑ Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018 Jan;27(1):60-75.
  28. ↑ Manchikanti L, Knezevic E, Latchaw RE, Knezevic NN, Abdi S, Sanapati MR, et al. Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain physician. 2022;25(7):E889–E916.
  29. ↑ Jayabalan P, Bergman R, Huang K, Maas M, Welty L. Relationship Between Socioeconomic Status and the Outcome of Lumbar Epidural Steroid Injections for Lumbar Radiculopathy. American journal of physical medicine & rehabilitation. 2023;102(1):52-57.
  30. ↑ George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., ... & Vining, R. (2021). Interventions for the management of acute and chronic low back pain: revision 2021: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1-CPG60.
  31. ↑ Huysmans E, Goudman L, Coppieters I, Van Bogaert W, Moens M, Buyl R, et al. Effect of perioperative pain neuroscience education in people undergoing surgery for lumbar radiculopathy: a multicentre randomised controlled trial. British Journal of Anaesthesia. 2023.
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