eMedicine Specialties > Sports Medicine > Spine
Lumbosacral Radiculopathy: Treatment & Medication
Updated: Jan 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
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.8 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.9,10 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.11 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.12,13 A study by Abrams reported that only 13 controlled, randomized trials had been published on the use of epidural steroid injections for back pain.13
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.14 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).15
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.16 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.12 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.
Recovery Phase
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.
Maintenance Phase
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.
Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of the initial treatment for LBP. With the use of all NSAIDs, elderly patients should be monitored for gastrointestinal (GI) and renal toxicity. Pain control with acetaminophen or a suitable narcotic may be more appropriate for elderly patients.
Muscle relaxant drugs are not first-line agents, but they may be considered for patients who are experiencing significant spasms. No studies have documented that these medications change the natural history of the disease. Because muscle relaxant drugs may cause drowsiness and dry mouth, the clinician may find it useful to recommend that these medications be taken at least 2 hours before bedtime.
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Diclofenac (Voltaren, Cataflam)
Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which in turn decreases the formation of prostaglandin precursors.
Adult
50 mg PO bid/tid
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into the CNS; do not administer to those at high risk of bleeding or to patients with peptic ulcer disease, recent GI bleeding or perforation, or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if leukopenia, granulocytopenia, or thrombocytopenia persists.
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
250-500 mg PO bid
Pediatric
<13 kg: 2.5 mL susp PO bid
14-25 kg: 5 mL/dose
26-38 kg: 7.5 mL/dose
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Muscle Relaxants
Muscle relaxant medications are used for radiculopathy that has a significant component of muscle spasm.
Cyclobenzaprine (Flexeril)
Skeletal-muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins that influence both alpha- and gamma-motor neurons. Structurally related to TCAs and, thus, carries some of the same risks.
Adult
10 mg PO tid initially; not to exceed 60 mg/d
Pediatric
Not established
Coadministration with MAOIs and TCAs may increase toxicity; cyclobenzaprine may have an additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine.
Documented hypersensitivity; those who have taken MAOIs within last 14 d
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with angle closure glaucoma and those with urinary hesitance
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who are in pain.
Oxycodone (OxyContin)
Indicated for the relief of moderate to severe pain.
Adult
10 mg PO bid initially
Pediatric
Not established
Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and TCAs may increase toxicity.
Documented hypersensitivity; patients with significant history of respiratory depression and whose respiratory functions are not being closely monitored; severe bronchial asthma; hypercarbia, paralytic ileus
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in the presence of COPD, emphysema, and renal insufficiency
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet, Roxilox)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease the analgesic effects of this medication; the toxicity increases with the coadministration of CNS depressants or TCAs.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The duration of action may increase in elderly persons; be aware of the total daily dose of acetaminophen the patient is receiving; do not exceed 4000 mg/d; higher doses may cause liver toxicity.
Tramadol (Ultram)
Inhibits the ascending pain pathways, altering perception of and response to pain. Also inhibits the reuptake of norepinephrine and serotonin.
Adult
50-100 mg PO q4-6h; not to exceed 400 mg/d
Pediatric
Not established
Decreases carbamazepine effects significantly; cimetidine increases toxicity; risk of serotonin syndrome with coadministration of antidepressants
Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or that taken within 14 days; use of SSRIs, TCAs, opioids; acute alcohol intoxication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust the dose in the presence of liver disease, myxedema, hypothyroidism, hypoadrenalism; pregnancy, breast-feeding; seizure; there is a risk of development of tolerance or dependency with extended use; swallow the extended-release product whole (do not chew, crush, or split)
Anticonvulsant
Some agents in this category are used to manage pain.
Gabapentin (Neurontin)
Membrane stabilizer, a structural analogue of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), which paradoxically is thought not to exert effects on GABA receptors. Appears to exert action via the alpha(2)-delta1 and alpha(2)-delta2 auxiliary subunits of voltage-gaited calcium channels.
Used to manage pain and provide sedation in neuropathic pain.
Adult
300 mg/d PO initially; gradually increase; mean dose is 2400 mg/d
Pediatric
Not established
Antacids may significantly reduce the bioavailability of gabapentin (administer at least 2 h after the use of antacids); may increase norethindrone levels significantly
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with severe renal disease
More on Lumbosacral Radiculopathy |
| Overview: Lumbosacral Radiculopathy |
| Differential Diagnoses & Workup: Lumbosacral Radiculopathy |
 Treatment & Medication: Lumbosacral Radiculopathy |
| Follow-up: Lumbosacral Radiculopathy |
| Multimedia: Lumbosacral Radiculopathy |
| References |
| « Previous Page | Next Page » |
References
Bull RC, ed. Dance injuries. Bull's Handbook of Sports Injuries. Baltimore, Md: McGraw-Hill; 1999:627-8.
Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:844-6.
Birnbaum JS. The Musculoskeletal Manual. 2nd ed. Orlando, Fla: Greene & Stratton; 1986:135.
Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. May 2007;25(2):387-405. [Medline].
Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. Feb 2004;86-A(2):382-96. [Medline]. [Full Text].
Padua L, Commodari I, Zappia M, Pazzaglia C, Tonali PA. Misdiagnosis of lumbar-sacral radiculopathy: usefulness of combination of EMG and ultrasound. Neurol Sci. Jun 2007;28(3):154-5. [Medline].
Tsao B. The electrodiagnosis of cervical and lumbosacral radiculopathy. Neurol Clin. May 2007;25(2):473-94. [Medline].
Barr KP, Griggs M, Cadby T. Lumbar stabilization: a review of core concepts and current literature, part 2. Am J Phys Med Rehabil. Jan 2007;86(1):72-80. [Medline].
Willardson JM. Core stability training: applications to sports conditioning programs. J Strength Cond Res. Aug 2007;21(3):979-85. [Medline].
Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. Mar 2004;85(3 suppl 1):S86-92. [Medline].
Memmo PA, Nadler SF, Malanga GA. Lumbar disc herniation: a review of surgical and non-surgical indications and outcomes. J Back Musculoskelet Rehabil. 2000;14(3):79-88.
Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. Jul 15 2007;32(16):1754-60. [Medline].
Abram SE. Treatment of lumbosacral radiculopathy with epidural steroids. Anesthesiology. Dec 1999;91(6):1937-41. [Medline].
Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil. Nov 1998;79(11):1362-6. [Medline].
Cyteval C, Fescquet N, Thomas E, et al. Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy. AJNR Am J Neuroradiol. May 2006;27(5):978-82. [Medline]. [Full Text].
DePalma MJ, Bhargava A, Slipman CW. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil. Jul 2005;86(7):1477-83. [Medline].
Borg-Stein J, Wilkins A. Soft tissue determinants of low back pain. Curr Pain Headache Rep. Oct 2006;10(5):339-44. [Medline].
Brown FW. Management of diskogenic pain using epidural and intrathecal steroids. Clin Orthop Relat Res. Nov-Dec 1977;129:72-8. [Medline].
Burnett C, Day M. Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol. Aug 2008;21(4):452-6. [Medline].
Cohen SP, Wenzell D, Hurley RW, et al. A double-blind, placebo-controlled, dose-response pilot study evaluating intradiscal etanercept in patients with chronic discogenic low back pain or lumbosacral radiculopathy. Anesthesiology. Jul 2007;107(1):99-105. [Medline].
Dimar JR 2nd, Glassman SD, Carreon LY. Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging. Spine J. May-Jun 2007;7(3):332-7. [Medline].
[Best Evidence] Dworkin RH, O'Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. Dec 5 2007;132(3):237-51. [Medline].
Fisher MA, Bajwa R, Somashekar KN. Routine electrodiagnosis and a multiparameter technique in lumbosacral radiculopathies. Acta Neurol Scand. Aug 2008;118(2):99-105. [Medline].
Gordon SL, Weinstein JN. A review of basic science issues in low back pain. Phys Med Rehabil Clin N Am. May 1998;9(2):323-42, vii. [Medline].
Hyun JK, Lee JY, Lee SJ, Jeon JY. Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine. Oct 1 2007;32(21):E598-602. [Medline].
Katayama Y, Matsuyama Y, Yoshihara H, et al. Comparison of surgical outcomes between macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon. J Spinal Disord Tech. Jul 2006;19(5):344-7. [Medline].
Kirita T, Takebayashi T, Mizuno S, et al. Electrophysiologic changes in dorsal root ganglion neurons and behavioral changes in a lumbar radiculopathy model. Spine. Jan 15 2007;32(2):E65-72. [Medline].
Malanga GA, Nadler SF. Nonoperative treatment of low back pain. Mayo Clin Proc. Nov 1999;74(11):1135-48. [Medline].
Morso L, Hartvigsen J, Puggaard L, Manniche C. Nordic walking and chronic low back pain: design of a randomized clinical trial. BMC Musculoskelet Disord. 2006;7:77. [Medline]. [Full Text].
Smeets RJ, Wade D, Hidding A, et al. The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review. Disabil Rehabil. Jun 15 2006;28(11):673-93. [Medline].
van Rijn JC, Klemetso N, Reitsma JB, et al. Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: Clinical examination compared with MRI. Clin Neurol Neurosurg. Sep 2006;108(6):553-7. [Medline].
Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. Jul 2007;38(3):363-72; abstract vi. [Medline].
Further Reading
Keywords
lumbosacral radiculopathy, back pain, sciatica, herniated disc, herniated disk, nucleus pulposus, pinched nerve, referred leg pain, acute low back pain, chronic low back pain, LBP, lumbosacral radicular syndrome, LRS, lumbosacral radiculitis, lumbosacral nerve root compression
