What is the diagnosis and treatment for radiculopathy (radicular pain or nerve root disorder)?

From the Guidelines

Radiculopathy treatment should prioritize conservative measures, including rest, activity modification, and over-the-counter pain medications such as NSAIDs, with consideration of physical therapy and short-term prescription medications for moderate to severe pain, as most cases resolve within 6-12 weeks with conservative management 1.

Key Considerations

• Conservative measures should be the initial approach for treating radiculopathy, focusing on rest, activity modification, and over-the-counter pain medications like NSAIDs (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) for 1-2 weeks.
• Physical therapy, specifically spine-stabilizing exercises, should be initiated within 2-4 weeks of symptom onset to support recovery and reduce pain.
• For moderate to severe pain, short-term prescription medications may include muscle relaxants like cyclobenzaprine (5-10mg three times daily for 1-2 weeks) or a brief course of oral steroids such as prednisone (starting at 60mg daily and tapering over 5-7 days).
• Epidural steroid injections can be considered for persistent symptoms, especially if there's evidence of nerve root compression or inflammation.
• Surgery may be necessary for patients with progressive neurological deficits, severe uncontrolled pain, or symptoms persisting beyond 6-12 weeks despite conservative treatment.

Diagnostic Approach

• Diagnostic imaging, such as MRI or CT, should be reserved for patients with severe or progressive neurologic deficits, or when serious underlying conditions are suspected based on history and physical examination 1.
• For patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis, MRI (preferred) or CT should be considered only if they are potential candidates for surgery or epidural steroid injection 1.

Treatment Outcomes

• Most radiculopathy cases (80-90%) resolve within 6-12 weeks with conservative management, emphasizing the importance of initial conservative treatment approaches.
• The decision to proceed with more invasive treatments, such as surgery, should be based on the severity of symptoms, patient preferences, surgical risks, and costs, and generally requires specialist input 1.

From the Research

Definition and Symptoms of Radiculopathy

• Radiculopathy refers to pain in one or both of the upper extremities, often accompanied by neck pain, secondary to compression or irritation of nerve roots in the cervical spine 2.
• It can be accompanied by motor, sensory, or reflex deficits and is most prevalent in persons 50 to 54 years of age 2.
• The most common examination findings are painful neck movements and muscle spasm, with diminished deep tendon reflexes being the most common neurologic finding 2.

Diagnosis of Radiculopathy

• The Spurling test, shoulder abduction test, and upper limb tension test can be used to confirm the diagnosis of cervical radiculopathy 2.
• Imaging is not required unless there is a history of trauma, persistent symptoms, or red flags for malignancy, myelopathy, or abscess 2.
• Electrodiagnostic testing is not needed if the diagnosis is clear, but has clinical utility when peripheral neuropathy of the upper extremity is a likely alternate diagnosis 2.

Treatment Options for Radiculopathy

• Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage 2.
• Epidural steroid injections may be helpful but have higher risks of serious complications 2.
• Paravertebral injections of a gas mixture of Oxygen and Ozone have been shown to be effective in reducing pain and discomfort in patients with lumbar radiculopathies caused by disc herniation 3.
• Pharmaceutical treatments for radiculopathy include opioid, antiinflammatory, neuromodulating, topical, and adjuvant treatments 4.
• Treatment of lumbar radiculopathy requires a multimodal and multispecialty team, including physical therapy, occupational therapy, physical and rehabilitation medicine, and pain management 5.