Treatment Guidelines for Radicular Pain
A stepped care approach is recommended for radicular pain, beginning with conservative management and progressing to interventional therapies based on pain severity, with early specialist referral (within 2 weeks) for severe cases with neurological deficits. 1
Diagnostic Approach
- MRI should not be used at primary care level for initial evaluation of radicular pain as it is too sensitive and not specific enough for screening purposes 2
- Imaging for radicular symptoms should only be requested by clinicians with the skills to interpret the images 1
- For severe radicular pain (disabling, intrusive, preventing normal activities) or patients with neurological deficits, earlier referral within 2 weeks of presentation is recommended 1
Initial Management
- A biopsychosocial assessment should be conducted to develop an appropriate management plan with the patient 1
- For less severe radicular pain, referral to specialist services should occur not later than 3 months (earlier if pain is severe) 1
- Exercise therapy with or without other treatments can be beneficial for radicular pain 3
Pharmacological Management
- Evidence for medication effectiveness in radicular pain is limited compared to non-radicular back pain 1
- NSAIDs have inconsistent results for radicular pain, with insufficient evidence to make strong recommendations 1
- Antidepressants such as duloxetine have shown small improvements in pain intensity and function in chronic low back pain (moderate-quality evidence) and may be considered for radicular pain 1, 2
- Benzodiazepines (diazepam) showed no benefit and potentially worse outcomes compared to placebo for radicular pain (low-quality evidence) 1
- Moderate-quality evidence shows no differences in pain between systemic corticosteroids and placebo for radicular low back pain 1
- Opioids should be used with tight restrictions, at the lowest possible dose for the shortest time possible, with close monitoring of efficacy and side effects 1
Interventional Treatments
- For severe radicular pain not responding to conservative management, image-guided steroid injections should be considered 1
- Fluoroscopic guidance is the gold standard for targeted epidural or transforaminal injections; blind injections should not be performed 1, 2
- Transforaminal corticosteroid administration is recommended for subacute lumbosacral radicular pain below level L3 resulting from contained herniation 4
- For chronic lumbosacral radicular pain, pulsed radiofrequency treatment adjacent to the dorsal root ganglion can be considered 3, 4
- In patients with therapy-resistant radicular pain in the context of Failed Back Surgery Syndrome, spinal cord stimulation is recommended 4
Timing of Treatment Escalation
- Patients with severe radicular pain or neurological deficits should be referred to specialist services within 2 weeks of presentation 1
- For less severe radicular pain, conservative management should be attempted first, with specialist referral if not improving by 3 months 1
- Surgery may be considered based on patient choice and clinical appropriateness when conservative and interventional approaches fail 1
Common Pitfalls and Caveats
- Radicular pain often responds poorly to simple analgesics and neuropathic pain medications, requiring a specialized care pathway 1
- Polypharmacy increases risk of adverse events and drug interactions, requiring careful monitoring 2
- Lumbar radiculopathy appears relatively refractory to many first and second-line medications, including opioids 2
- The use of opioids in radicular pain management is controversial due to lack of evidence for long-term benefit and risk of dependence 1
- Patients on multiple centrally-acting medications have increased risk of CNS side effects including sedation 2