Lumbar Radiculopathy Treatment

Original Editor - Matt Huey

Top Contributors - Matt Huey and Jess Bell  

Introduction[edit | edit source]

Lumbar radiculopathy is commonly caused by compression of a lumbar nerve root, resulting in symptoms which radiate down the legs. Symptoms include altered sensation, decreased reflexes, weakness, and pain, which may be described as sharp, shocks, burning, tingling, etc. Lumbar radiculopathy affects approximately 3-5% of the population. Males are more likely to experience lumbar radiculopathy when they are in their 40s, and females are more likely to experience it in their 50s and 60s.[1]

There are many different treatments utilised in the management of lumbar radiculopathy. It is still not clear which treatments are optimal, and treatment choice will depend on individual factors, including the cause of symptoms (e.g. venous congestion, disc impinging on the neural foramen, bony growth or disc degeneration).[2]

Current treatments include invasive procedures (e.g. surgery and injections), non-invasive procedures (e.g. education, manual therapy, exercise) and pharmacological management (e.g. non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids). Often, a combination of interventions may be required.

Remember, we can use the Treatment-based Classification System to guide our approach to managing individuals with low back pain with or without lumbar radiculopathy. For more information on this system, please see:

Assessment for Lumbar Radiculopathy[edit | edit source]

The assessment for lumbar radiculopathy should include a subjective evaluation, which covers the history, aggravating / easing factors, and location of symptoms, as well as an objective assessment.

Objective measures can include:

These tests should not be performed in isolation but 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 serious pathology, such as cauda equina syndrome, cancer, or fractures. When considering prevalence, there are a few things to keep in mind:[4]

  • red flags will often be more prevalent in certain areas of medicine (e.g. a spinal surgeon will see more individuals with red flags than a physiotherapist)
  • emergency room physicians will see more individuals with 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 will need further investigation, including:[5]

  • recent trauma, especially in individuals aged over 50 years: this raises the chance of a vertebral fracture
  • history of cancer
  • recent history of infection
  • bladder or bowel dysfunction (including urinary retention, loss of bladder / bowel control)
  • pain that wakes the patient up 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.[6] This framework encourages clinicians to not solely rely on a single red flag but to instead assess the patient's context alongside the red flag(s), taking into account factors such as symptom progression and co-existing conditions. Based on the findings, clinicians consider the level of concern and take appropriate action:[6]

  • 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 a 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.

Key Interventions for Lumbar Radiculopathy[edit | edit source]

The management of lumbar radiculopathy often incorporates multiple interventions. The following sections outline the evidence for specific interventions for lumbar radiculopathy. Most of the evidence presented considers interventions utilised in conjunction with other interventions. All of the following treatments can be used alongside other interventions.

Manual Therapy[edit | edit source]

Manual therapy techniques include a range of hands-on approaches. Common manual therapy techniques for patients experiencing lumbar radiculopathy include mobilisation of the lumbar spine, mobilisation of the nerves, or manipulation. Always check for contraindications and consider your skill level and the patient's level of comfort before selecting manual therapy interventions. Some patients are very irritable, and manual therapy techniques may intensify their 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 suggest that spinal mobilisation can be beneficial for lumbar radiculopathy. Several studies have found that spinal mobilisations combined with leg movement can help decrease pain.[7] [8][9][10] In these studies, mobilisations were used alongside other treatments, including exercise and modalities.

Therefore, mobilisations can make up part of the treatment for lumbar radiculopathy.

Mobilisation of the Nerve[edit | edit source]

Mobilisation of the sciatic or femoral nerves involves tensioning or gliding 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.[11]

These techniques can be beneficial for patients experiencing acute symptoms as they can help decrease sensitivity. They can also be utilised with individuals with a possible entrapment.

The following videos demonstrate mobilisation techniques for the sciatic nerve and the femoral nerve.

[12]
[13]
[14]

Manipulation of the Lumbar spine[edit | edit source]

High velocity, low amplitude (HVLA) thrust manipulations or manipulation techniques are quick, passive movements applied to a specific level of the spine or as a general technique. There is evidence demonstrating that manipulations can be beneficial for individuals with lumbar radiculopathy.[15] Additionally, there is evidence suggesting that incorporating manipulation techniques into the care plan for lumbar radiculopathy can decrease the use of benzodiazepines[16] and the chance of discectomy.[17]

The literature concludes that manipulation should be used as an adjunct to other treatments, including exercise.

Exercise[edit | edit source]

There is evidence to support the use of exercise in the treatment of lumbar radiculopathy.[18] However, the literature does not always specify what "exercise" entails. 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 has been suggested that if there is a disruption in the motor control in the spine, stabilisation activities can help restore motor control and decrease pain. Again, most research considers stabilisation exercises alongside other interventions, such as spinal manipulation and extension movements, such as cat-camel or a seated lumbar extension.[19][20][21]

Repeated movements are 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 symptoms. It has been found that patients who can centralise their symptoms may have better outcomes.[22]

The following videos demonstrate how repeated extensions can be performed in prone and standing.

[23]
[24]

Please note that while there is often a focus on extension-based movements, repeated movements may involve movements in the sagittal plane (flexion / extension), frontal plane (lateral), or a combination of movements, depending on the patient's directional preference.

General physical activity / cardiovascular exercise should also be considered. Thoomes et al.[25] note that individualised physical activity is beneficial in the acute phase of conservative management for lumbar radiculopathy. In the chronic phase, other types of exercise were recommended, including general aerobic exercise, general strength training, focused / targeted strength training, individualised physical activity, supervised exercise, etc. Options to consider include walking, biking, swimming, ski ergometer, etc.[2]

Education[edit | edit source]

Education is a staple of treatment for many conditions, including lumbar radiculopathy.[18] Patient education is recommended in clinical guidelines for treating back pain and lumbar radiculopathy.[26] It is important to note that "education" is a broad term; it could refer to many different things, including maintaining a healthy lifestyle (e.g. healthy diet and getting enough sleep), lifting mechanics, posture, and overall activity.

When planning patient education, we must consider what information our patients want. A systematic review by Lim et al.[27] found that patients with low back pain, including lumbar radiculopathy, want to understand the following:[27]

  • their diagnosis and the cause of their symptoms (however, this may contribute "to expectations for and overuse of imaging"[27])
  • a personalised management strategy, including pharmacological and non-pharmacological management strategies
  • consistent information on the nature of low back pain, along with management strategies

Moreover, they want this information to be presented so it is easily understood and is appropriate for their age, lifestyle, and occupational status.[27]

Modalities[edit | edit source]

Different modalities are commonly utilised in rehabilitation settings. 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 evidence they may have some benefit when used in conjunction with other interventions.[28][29] There is also some evidence that traction can help reduce pain in individuals with lumbar radiculopathy in the short term.[30]

Medication[edit | edit source]

There is mixed evidence for the use of medication in the treatment of lumbar radiculopathy.[18] 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,[31] but have a limited benefit in the long term. Recent guidelines recommend against the use of NSAIDs and other opioids in the treatment of lumbar radiculopathy.[32] Anticonvulsants (such as gabapentin or pregabalin) are also sometimes prescribed for radicular symptoms, but there is evidence that these are largely ineffective for the treatment of lumbar radiculopathy.[33]

Epidural Injection[edit | edit source]

An epidural injection may be suggested for individuals with lumbar radiculopathy who do not improve with conservative management.[1] However, there is mixed evidence for their use,[18] [26][34] and other factors, such as socioeconomic status, may influence outcomes. For instance, Jayabalan et al. found that "Lower socioeconomic status was independently associated with higher pain alleviation after controlling for other potentially influential demographics."[35]

Surgery[edit | edit source]

Individuals with red flags or progressive neurologic loss will need to be reviewed by the relevant specialist (e.g. neurosurgeon / neurologist). Surgery may also be considered as an option for patients who do not improve with conservative treatment.[18] 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]

Rehabilitation and patient education are recommended for individuals who have had lumbar surgery.[36] 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.[37]

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. ↑ 2.0 2.1 Rainey N. Lumbar Radiculopathy Treatment Course. Plus, 2024.
  3. ↑ Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. Treatment-based classification system for low back pain: revision and update. Physical therapy. 2016 Jul 1;96(7):1057-66.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 6.0 6.1 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ Northern Lincolnshire and Goole NHS Foundation Trust. MSK Sciatic Nerve Glides. Available from: https://www.youtube.com/watch?v=cZ-kEwWTmus [last accessed 19/2/2024]
  13. ↑ INSYNC PHYSIO Vancouver. Anterior Hip Pain: Femoral Nerve Glides Sidelye. Available from: https://www.youtube.com/watch?v=wDPjjPkJyEk [last accessed 19/2/2024]
  14. ↑ Rehab My Patient. Femoral nerve glide floss 4. Available from: https://www.youtube.com/watch?v=Wo1JgMRGSlI [last accessed 4/2/2024]
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA. 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 Dec 16;12(12):e068262.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 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.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ Danazumi MS. Physiotherapy management of lumbar disc herniation with radiculopathy: a narrative review. Nigerian Journal of Experimental and Clinical Biosciences. Jul-Dec 2019;7(2):93-100.
  22. ↑ Albert HB, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J. 2012 Apr;21(4):630-6.
  23. ↑ joel laing. McKenzie Method: Extension in lying for relief of back pain and sciatica. Available from: https://www.youtube.com/watch?v=kESRfUlaLP8 [last accessed 4/2/2024]
  24. ↑ joel laing. McKenzie Method: Extension in Standing. Available from: https://www.youtube.com/watch?v=zN8mpqLqB8o [last accessed 4/3/2024]
  25. ↑ Thoomes E, Falla D, Cleland JA, Fernández-de-Las-Peñas C, Gallina A, de Graaf M. Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study. Disabil Rehabil. 2023 Oct;45(21):3539-3548.
  26. ↑ 26.0 26.1 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.
  27. ↑ 27.0 27.1 27.2 27.3 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.
  28. ↑ 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.
  29. ↑ Divyasree S, Kumaresan A, Vishnuram S. Effect of Mckenzie lumbar extension exercise with TENS on lumbar radiculopathy. Biomedicine. 2023;43(3):1032-5.
  30. ↑ 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.
  31. ↑ 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.
  32. ↑ 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.
  33. ↑ 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.
  34. ↑ 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.
  35. ↑ 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.
  36. ↑ George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA. et al. 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. 2021;51(11):CPG1-CPG60.
  37. ↑ 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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