Lumbosacral Radiculopathy Treatment & Management

Rehabilitation Program

Physical Therapy

A method that is commonly referred to as "back school" involves teaching the patient back-protection techniques (eg, proper lifting, posture awareness). A lumbar stabilization program is another useful method that physical therapists may incorporate for patients with LBP.^[9] The patient is instructed in various techniques to control his or her back pain, and he or she also works on strengthening the stabilizing muscles of the lumbar spine. This is actually a combination of different techniques and may involve the McKenzie exercise program (a series of repetitive lumbar spine exercises for the management of LBP).

Core strengthening is advocated by many rehabilitation specialists as a means of improving muscular control around the lumbar spine to maintain functional stability.^{[10, 11]} The core muscles include the abdominals anteriorly, the paraspinals and gluteals posteriorly, the diaphragm as the roof, and the pelvic floor and hip girdle musculature as the floor. A typical program consists of a series of graded exercises that promote movement awareness and motor relearning in addition to strengthening.

Soft-tissue modalities are also usually incorporated into a back pain program. These modalities involve specific manual techniques, myofascial release, or massage to improve the soft-tissue component of a patient's pain.

The use of lumbar traction has long been a preferred method of treating lumbar disc problems. Lumbar traction requires approximately 1.5 times the person’s body weight to develop distraction of the vertebral bodies. However, this method can be cumbersome and time consuming; furthermore, most individuals find lumbar traction difficult to tolerate.

Vertebral axial decompression (VAX-D) is a relatively newer method that causes distraction of the vertebral bodies and probably represents a more technical version of traction. Currently, there is no evidence in the peer-reviewed literature to support this form of treatment. No significant difference in outcome has been demonstrated with traction relative to sham traction; however, greater morbidity has been demonstrated in the traction group. A limited amount of evidence supports its use. Given the effectiveness of more active treatments, traction is generally not recommended in the treatment of acute LBP.

The above techniques may also be used during the recovery phase, with a lifelong home exercise program forming part of the maintenance phase.

Surgical Intervention

Most sources agree on the urgent and definitive indications for surgical intervention in patients with lumbosacral radiculopathy (eg, significant/severe and progressive motor deficits, cauda equina syndrome with bowel and bladder dysfunction). The 5 surgical treatment options are as follows:

• Simple discectomy
• Discectomy plus fusion
• Chemonucleolysis
• Percutaneous discectomy
• Microdiscectomy

Ninety percent of patients who have surgery for lumbar disc herniation undergo discectomy alone, although the number of spinal fusion procedures has greatly increased.^[12] Additionally, the complication rate of simple discectomy is reported at less than 1%.

Other Treatment

Epidural steroid injections are a modality that appears promising, despite a paucity of well-designed trials of their efficacy.^{[13, 14]} A study by Abrams reported that only 13 controlled, randomized trials had been published on the use of epidural steroid injections for back pain.^[14] Although some controversy exists in the literature, caudal epidural steroid or saline injections may be another treatment option for chronic lumbar radiculopathy. A multicenter, blinded, randomized controlled trial conducted in Norway assessed the efficacy of caudal epidural steroid or saline injections in chronic lumbar radiculopathy at 6 weeks, 12 weeks, and 52 weeks. All patients studied improved after treatment, but no statistical or clinical differences were noted over time.^[15]

Lutz et al demonstrated an outcome success rate of 75.4% with the use of selective nerve blocks in conjunction with oral medications and physical therapy in patients who had a herniated lumbar nucleus pulposus and radiculopathy in whom conservative therapy had not yielded positive results.^[16] Other investigators also found similar benefits from the procedure. Although epidural steroid injections may be performed within months to years of symptom onset, with comparable symptomatic relief, the optimal time period is 6-9 months from onset. However, the growing consensus is that this treatment is most effective in acute cases (3-6 mo post onset).^[17]

In a review study, DePalma et al found level III (moderate) evidence supporting the use of transforaminal epidural steroid injections (TFESIs) in the treatment of lumbosacral radiculopathy.^[18] Six trials were analyzed in the review, and no significant complications were reported.

In another report, Friedly et al investigated trends of increasing lumbosacral injections (eg, epidural steroid injections [ESIs], facet joint injections, sacroiliac joint injections, and related fluoroscopy) for LBP from 1994-2000 in the Medicare population.^[13] The authors reviewed Medicare Part B claims data with use of Current Procedural Technology (CPT) billing codes from the relevant period and found a 271% increase in lumbar ESIs, an increase from $24 million to $175 million of the total inflation-adjusted reimbursed costs for professionals, and almost a doubling of the costs per injection, from $115 to $227.

Most clinicians agree that image-guided transforaminal epidural injections are preferred to an interlaminar or caudal approach. This technique routinely delivers medication to the anterior epidural space.

Rehabilitation Program

Physical Therapy

In the recovery phase, patients with lumbosacral radiculopathy should gradually progress in their physical therapy program to continue to decrease pain and focus on functional stabilization and back safety techniques. By the end of this phase, patients should be independent in an appropriate home exercise program.

Other Treatment (Injection, manipulation, etc.)

Manipulation/mobilization

Several studies have demonstrated the efficacy of manipulation and soft-tissue mobilization in the treatment of acute LBP; manual medicine techniques have been shown to relieve acute pain and reduce symptoms in the initial stages of treatment. The best effects are noted during the initial 1-4 weeks of therapy.

The initial manipulation prescription should be performed once per week in conjunction with the patient's exercise program. The incorporation of patient-activated treatment, termed muscle energy, can be performed up to 2-3 times per week and should be performed in conjunction with an active exercise program.

Regularly scheduled follow-up visits are necessary to monitor for changes in the patient's symptoms and/or physical examination findings.

Clear-cut goals of treatment should be established at the onset of the therapy. A lack of improvement after 3-4 treatments should result in discontinuation of the manipulation, and the patient should be reassessed.

Manual medicine treatment may be incorporated into the initial treatment of acute LBP to facilitate the patient’s active exercise program. Treating practitioners should be aware of the contraindications for manipulation, especially manipulation under anesthesia, which has been demonstrated to be a high-risk practice. Although superior patient satisfaction levels have been demonstrated among those patients who receive manipulation-based care, there is no supporting evidence for maintenance treatment once the acute pain episode has resolved.

Rehabilitation Program

Physical Therapy

Once discharged from physical therapy, the patient will be expected to continue his or her home exercise program on a regular basis, with the understanding that the management of lumbar radiculopathy is a long-term process.