What is the initial treatment for lumbar radiculopathy due to a herniated disc?

Initial Treatment for Lumbar Radiculopathy from Herniated Disc

First-Line Management

Conservative management should be the initial treatment for all patients with lumbar radiculopathy from herniated disc, unless red flags indicating cauda equina syndrome, progressive neurologic deficits, or cancer with impending spinal cord compression are present. 1, 2

The natural history of lumbar disc herniation with radiculopathy favors improvement within the first 4 weeks with noninvasive management in most patients 1. Prospective studies demonstrate that 43% of herniated discs completely resolve and 36% improve on imaging after conservative treatment, with sustained clinical improvement over 30 months of follow-up 3.

Conservative Treatment Components

Core Treatment Elements

• Physical therapy focusing on core strengthening and flexibility exercises is the cornerstone of initial treatment and should be initiated immediately 2, 4

• Patient education about the favorable prognosis is essential—clinicians must inform patients of the high likelihood for substantial improvement within the first month 1

• Activity modification with advice to remain active is more effective than bed rest for acute or subacute low back pain 1

• Pain medication including NSAIDs and muscle relaxants (such as cyclobenzaprine) can be used as adjunctive therapy 5, 6

Specific Physical Therapy Interventions with Moderate Evidence

The following interventions have Level B (moderate) evidence for effectiveness 6:

• McKenzie method
• Mobilization and manipulation techniques
• Exercise therapy programs
• Neural mobilization
• Traction (for short-term outcomes only)

Duration of Conservative Management

• At least 6 months of comprehensive conservative therapy should be completed before considering surgical intervention, unless red flags are present 2, 4

• Routine imaging (MRI or CT) is not recommended initially and does not improve outcomes 1

When to Obtain Imaging

MRI (preferred) or CT should only be ordered if patients are potential candidates for surgery or epidural steroid injection 1

Indications for imaging include:

• Persistent symptoms after 4 weeks of conservative management in surgical candidates 1
• Suspected cauda equina syndrome (urinary retention has 90% sensitivity) 4
• Progressive neurologic deficits 1, 4
• History of cancer or other red flags suggesting serious underlying conditions 1

Red Flags Requiring Urgent Evaluation

Prompt work-up with MRI is mandatory when the following are present 1:

• Urinary retention or bowel incontinence (cauda equina syndrome)
• Progressive motor weakness
• Saddle anesthesia
• History of cancer with new back pain
• Fever, weight loss, or immunosuppression suggesting infection

Delaying surgical consultation for cauda equina syndrome can result in permanent neurological damage 4

Epidural Steroid Injections

• Epidural steroid injections are a treatment option for persistent radicular symptoms despite conservative therapy 1
• These should only be considered after clinical correlation between symptoms and MRI findings is established 1, 4

Critical Pitfalls to Avoid

• Do not order routine imaging in the first 4 weeks unless red flags are present—imaging findings (such as bulging disc without nerve root impingement) are often nonspecific and do not correlate with clinical outcomes 1, 4

• Do not recommend bed rest—remaining active produces better outcomes than prolonged rest 1

• Do not proceed to surgery without completing at least 6 months of conservative management unless cauda equina syndrome, progressive neurologic deficits, or severe disabling pain refractory to all conservative measures is present 2, 4

• Over-reliance on imaging without clinical correlation leads to unnecessary surgical intervention—imaging findings must correlate with clinical symptoms 4

Surgical Considerations (When Conservative Management Fails)

Lumbar spinal fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy 1, 2, 4

Surgery should only be considered when 2, 4:

• Nonoperative treatments fail after at least 6 months
• Progressive neurological deficits develop
• Cauda equina syndrome is present
• Severe, disabling pain persists despite comprehensive conservative management

Simple discectomy without fusion is typically sufficient for patients with primarily radicular symptoms without significant chronic axial back pain 2

Fusion may be considered only in specific circumstances 1, 2:

• Significant chronic axial back pain in addition to radiculopathy
• Manual labor occupations (89% vs 53% work maintenance rate at 1 year)
• Severe degenerative changes with instability
• Recurrent disc herniations (92% improvement rate with fusion)

However, fusion increases surgical complexity, prolongs operative time, potentially increases complication rates, and delays return to work (25 weeks vs 12 weeks for discectomy alone) without proven medical necessity in most cases 1, 2