What are the treatment options for radiculopathy (radicular pain due to nerve root dysfunction)?

From the Guidelines

Treatment of radiculopathy should begin with conservative measures, including rest, gradual return to normal activities, and pain control with NSAIDs or gabapentin, as these approaches have been shown to provide small to moderate benefits in reducing pain and improving function 1.

Key Considerations

• Initial management includes rest for 24-48 hours, followed by a gradual return to normal activities.
• Pain control can be achieved with NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks.
• Gabapentin is associated with small, short-term benefits in patients with radiculopathy and has not been directly compared with other medications or treatments 1.
• For persistent symptoms, epidural steroid injections may provide temporary relief.
• Surgery (such as discectomy or laminectomy) is generally reserved for cases with progressive neurological deficits, intractable pain despite 6-12 weeks of conservative treatment, or cauda equina syndrome, which requires immediate surgical intervention.

Nonpharmacologic Therapy

• Physical therapy focusing on stretching, strengthening, and proper body mechanics should be initiated after acute pain subsides, typically within 2-4 weeks of symptom onset.
• Intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation may be considered for patients who do not improve with self-care options 1.

Important Notes

• Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1.
• Benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief but are also associated with risks for abuse, addiction, and tolerance 1.
• Most radiculopathy cases (80-90%) improve with conservative management within 6-12 weeks as inflammation subsides and the body's natural healing processes occur.

From the Research

Treatment Options for Radiculopathy

The treatment options for radiculopathy, also known as radicular pain due to nerve root dysfunction, can be categorized into non-surgical and surgical management.

• Non-surgical management includes:
  • Conservative treatment, such as physical therapy (PT), occupational therapy (OT), and pain management 2
  • Biological treatments, including ultra-sound-guided periradicular injections of ACS or PRP, which have shown to be effective in reducing pain and improving disability index and proprioception of the hand 3
  • Physical treatments, such as laser therapy or collagen magnetophoresis, which can produce improvement in pain and disability indicators, but may not have evident regenerative effects 3
  • Mechanical treatments, including manual therapy or traction therapy, which can be effective in reducing pain and disability, but may have limitations and potential risks, such as exacerbation of symptoms 3, 4
• Surgical management includes:
  • Anterior cervical discectomy and fusion (ACDF), which has been widely used and proven to be safe and effective 5
  • Cervical disc replacement (CDR), which is designed to reduce the incidence of adjacent segment disease and maintain cervical spine motion postoperatively 5
  • Posterior cervical foraminotomy, which is a safe and effective surgical option to avoid complications associated with anterior approach and fusion surgery 5

Timing of Interventions

The timing of nonsurgical interventions is also an important consideration in the management of cervical radiculopathy.

• In the acute stage, the focus should be on patient education, spinal manipulative therapy, specific exercises, and sustained pain-relieving positions 6
• In the subacute stage, increasing individualized physical activity, including supervised motor control, specific exercises, and/or neurodynamic mobilization, can be added 6
• In the chronic stage, the focus should shift to include general aerobic exercise, focused strength training, postural education, and vocational ergonomic assessment 6

Effectiveness of Treatments

The effectiveness of conservative treatments for patients with cervical radiculopathy has been studied, and the results suggest that:

• No one intervention seems to be superior or consistently more effective than other interventions 4
• Patients seem to improve over time, indicating a favorable natural course 4
• The use of a collar and physiotherapy show promising results at short-term follow-up 4