What is the best course of treatment for a patient with unilateral radiculopathic lumbar pain referred to the left thigh?

Management of Unilateral Radiculopathic Lumbar Pain

Begin with conservative management for at least 6 weeks before considering imaging or invasive interventions, unless red flag symptoms are present. 1, 2

Initial Conservative Treatment (First 6 Weeks)

Pharmacologic Management

• Start with NSAIDs as first-line medication for pain control, which have proven benefits for radiculopathy 1, 2
• Add gabapentin for neuropathic pain, as it provides small, short-term benefits in radiculopathy with moderate evidence 3
• Consider muscle relaxants for associated muscle spasms, though avoid skeletal muscle relaxants for radiculopathy itself due to CNS adverse effects 2, 3
• Use short-term opioids judiciously only for severe pain at the lowest dose for the shortest duration 2, 3
• Avoid systemic corticosteroids as they are not more effective than placebo for sciatica 3
• Do not use benzodiazepines routinely due to risks of abuse, addiction, and tolerance 3

Non-Pharmacologic Management

• Advise the patient to remain active rather than bed rest, which is more effective for radicular pain 1, 2, 4
• Initiate physiotherapy immediately within 2 weeks of symptom onset for optimal outcomes 2
• Provide activity modification without complete restriction 2
• Apply heat/cold therapy as needed for symptomatic relief 2
• Educate the patient about the favorable natural history—most disc herniations show reabsorption by 8 weeks 1, 2

When to Obtain Imaging

Do NOT Image Initially

• Imaging is not appropriate for initial evaluation of radiculopathy without red flags 1, 2
• Routine imaging provides no clinical benefit and increases healthcare utilization without improving outcomes 1, 2
• Disc abnormalities are present in 29-43% of asymptomatic individuals and may not correlate with symptoms 2

Image Immediately for Red Flags

Obtain MRI lumbar spine without IV contrast urgently if any of the following are present: 1, 2

• Cauda equina syndrome (urinary retention/incontinence, bilateral weakness, saddle anesthesia)
• Progressive neurological deficits (e.g., worsening foot drop, progressive motor weakness)
• Suspected malignancy
• Suspected infection
• Fracture

Image After 6 Weeks of Failed Conservative Therapy

• Order MRI lumbar spine without IV contrast only after 6 weeks of optimal conservative management if the patient is a potential candidate for surgery or epidural steroid injection 1, 2
• MRI is preferred over CT for better visualization of soft tissue, nerve roots, and spinal canal 1, 3

Escalation After Failed Conservative Management

Specialist Referral Timing

• Refer within 2 weeks if pain is severe, disabling, intrusive, or if neurological deficits are present 2, 3
• Refer no later than 3 months for less severe but persistent radicular pain 2, 3

Interventional Options

• Consider fluoroscopically-guided epidural steroid injections (transforaminal or interlaminar) after 6 weeks of failed conservative therapy 2, 3, 5
• Fluoroscopic guidance is the gold standard; blind injections should not be performed 2
• Injections provide targeted delivery and confirmation of proper placement 2

Surgical Evaluation

• Refer for surgical evaluation if progressive neurological deficits or severe radiculopathy refractory to conservative measures and epidural injections 2, 3, 4
• Discectomy is appropriate for persistent radicular symptoms with documented nerve root compression on imaging 2, 3
• Lumbar fusion is NOT recommended for routine disc herniation causing radiculopathy, as it increases complexity and complication rates without proven benefit 2, 3

Critical Pitfalls to Avoid

• Do not order imaging before 6 weeks unless red flags are present—this leads to unnecessary healthcare utilization without benefit 1, 2
• Do not prescribe bed rest—patients should remain active as tolerated 1, 2
• Do not delay specialist referral beyond 3 months for persistent symptoms, as this prolongs disability 2, 3
• Do not use systemic corticosteroids for radiculopathy—they lack efficacy 3
• Do not perform blind injections—always use fluoroscopic guidance for safety and efficacy 2

Natural History Context

Over 50% of lumbar radicular pain cases resolve with simple analgesics and conservative management 4. The majority of disc herniations demonstrate reabsorption or regression by 8 weeks after symptom onset 1, 2. Most patients improve within the first 4 weeks with noninvasive management 1, 2. This favorable natural history supports the conservative-first approach and explains why routine early imaging is unnecessary and potentially harmful.