Treatment for Muscle Spasms and Radiculopathy
For radiculopathy, systemic corticosteroids are not recommended as they provide no benefit for pain relief or functional improvement, while skeletal muscle relaxants are effective for acute muscle spasms but cause significant sedation. 1
Pharmacologic Management
For Radiculopathy
The evidence is clear and consistent: systemic corticosteroids (oral prednisone or intramuscular dexamethasone) show no difference from placebo in reducing pain for radicular low back pain 1. Six trials consistently demonstrated this lack of efficacy, and while one large trial (n=269) showed a small functional improvement at 52 weeks, this was offset by significantly increased adverse events including insomnia (26% vs 10%), nervousness (18% vs 8%), and increased appetite (22% vs 10%) 1.
NSAIDs remain a reasonable option for acute radiculopathy, though benefits are small (5-10 points on a 100-point scale) and short-term 1.
For Muscle Spasms
Skeletal muscle relaxants effectively relieve short-term acute muscle spasms with moderate strength of evidence 1. However, sedation is a consistent side effect that must be weighed against benefits. These should be used for acute presentations only, not chronic conditions.
Benzodiazepines showed no functional benefit and actually increased pain in radiculopathy patients, making them a poor choice 1.
Non-Pharmacologic Management
Stage-Based Approach for Radiculopathy
Acute Stage (< 6 weeks):
- Patient education about the condition and pain mechanisms
- Individualized physical activity maintenance
- Directional preference exercises (McKenzie approach)
- NSAIDs for symptom control 2
Subacute Stage (6-12 weeks):
- Add neurodynamic mobilization techniques
- Initiate strength training
- Consider transforaminal/epidural steroid injections if conservative measures fail 2
- Manual therapy combined with exercise shows quantifiable benefits: mean pain reduction of 2.0 points at 2 weeks and 2.6 points at 6 months 3
Chronic Stage (> 12 weeks):
- Spinal manipulative therapy
- Function-specific physical training
- Individualized vocational and ergonomic modifications 2
Specific Manual Therapy Techniques
Combined spinal mobilization with leg movement (SMWLM) plus progressive inhibition of neuromuscular structures (PINS) demonstrates superior outcomes compared to either technique alone 4. Neural mobilization alone reduced pain by 2.4 points and disability by 12.8% at 8 weeks compared to traditional therapy 3.
Critical Clinical Pitfalls
Do not prescribe systemic corticosteroids for radiculopathy - the evidence consistently shows no benefit with clear harm 1. This is a common error in practice that should be avoided.
Recognize that active myofascial trigger points occur in 51% of cervical radiculopathy patients, most commonly in levator scapulae (16.3%), splenius capitis (14.7%), and upper trapezius (13.5%) 5. These require specific trigger point treatment in addition to addressing the radiculopathy itself.
Muscle spasms may reflect reflex inhibitory mechanisms from nerve irritation rather than primary muscle pathology 6. Treating the underlying nerve compression or irritation (whether through manual therapy, injections, or surgery) can release paraspinal muscle spasm more effectively than treating the spasm alone.
Treatment Algorithm
- Initial presentation: NSAIDs + skeletal muscle relaxants (short-term) + patient education + maintain activity
- If no improvement by 2-4 weeks: Add manual therapy (SMWLM + PINS) + directional preference exercises
- If inadequate response by 6-8 weeks: Add neurodynamic mobilization + strength training; consider epidural/transforaminal injections
- If persistent beyond 12 weeks: Intensify function-specific training + spinal manipulation + address trigger points + vocational modifications
- Surgical consultation: Reserved for progressive neurologic deficit or failure of comprehensive conservative management
The evidence strongly supports avoiding corticosteroids while utilizing a staged approach combining manual therapy, specific exercises, and judicious use of muscle relaxants for acute spasms 1, 2, 3.