From the Guidelines
Radiculopathy treatment should prioritize a stepped care approach, starting with conservative measures such as rest, physical therapy, and over-the-counter pain medications, and progressing to more invasive therapies like image-guided steroid injections or surgery only if necessary, as recommended by the British Pain Society in 2013 1.
Key Considerations
- For acute radiculopathy, rest for 24-48 hours may help, followed by gradual return to normal activities.
- Over-the-counter pain medications like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) can reduce inflammation and pain.
- Physical therapy focusing on spine-stabilizing exercises is often beneficial after the acute phase.
- For severe pain, prescription medications such as muscle relaxants (cyclobenzaprine 5-10mg three times daily), gabapentin (starting at 300mg daily and increasing gradually), or short-term oral steroids (prednisone taper starting at 60mg daily) may be necessary.
Treatment Approach
- A care pathway for radicular pain should be developed, recognizing neuropathic pain caused by radiculopathy and treating it within a unique care pathway 1.
- Early investigation, pharmacotherapy, and invasive therapies should be considered for patients with severe radicular pain or neurological deficit.
- The timing of treatment for severe radicular pain is controversial, but earlier referral (within 2 weeks of presentation) might help, as suggested by the British Pain Society in 2013 1.
Important Notes
- Most radiculopathies improve within 6-12 weeks with conservative treatment.
- Surgery may be considered for cases with progressive neurological deficits or pain that doesn't respond to conservative measures.
- The American College of Physicians and the American Pain Society recommend against the use of systemic corticosteroids for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1.
From the Research
Definition and Treatment of Radiculopathy
- Radiculopathy refers to a condition where a nerve root in the spinal column becomes inflamed or damaged, leading to pain and other symptoms 2, 3.
- The treatment of radiculopathy can involve various approaches, including epidural steroid injections, physical therapy, and pharmaceutical therapy 2, 3, 4.
Epidural Steroid Injections
- Epidural steroid injections (ESI) can be an effective treatment for radicular pain, with three main interventional approaches: interlaminar, transforaminal, and caudal 2.
- The transforaminal route has the most robust efficacy data, but the selection of an injection approach should be based on a patient's clinical presentation, pathology, anatomy, and unique risks and benefits of the technique 2.
Pharmaceutical Therapy
- Pharmaceutical treatments for radiculopathy include opioid, anti-inflammatory, neuromodulating, topical, and adjuvant treatments 4.
- Gabapentinoids, such as pregabalin and gabapentin, can be used to relieve pain after transforaminal epidural steroid injection, with similar effectiveness 5.
Natural History and Prognosis
- Most cases of radiculopathy are self-limiting, with symptoms resolving over the course of weeks to months 6.
- Knowledge of the natural history of radiculopathy is crucial for healthcare providers to appropriately counsel and treat patients with this disorder 6.
Diagnosis and Management
- Diagnostic modalities, including magnetic resonance imaging (MRI), computerized tomography (CT), contrast myelogram, electromyogram (EMG), and nerve conduction velocity (NCV), are involved in the diagnosis and decision-making of lumbar radiculopathy 3.
- Treatment of lumbar radiculopathy requires a multimodal and multispecialty team, including physical therapy, occupational therapy, physical and rehabilitation medicine, and pain management 3.