Treating lumbar radiculopathy

Let’s discuss how to manage lumbar radiculopathy. If you are fairly convinced that your patient has lumbar radiculopathy, and there are no red flags present, there is no immediate need for magnetic resonance imaging (MRI). Instead, the patient can be treated conservatively and reassured that the condition will likely go away with time.

Comfort measures

Advise the patient to seek comfort. This is individualized and may mean bed rest, pacing about, or sitting in a lounger. Mandatory bed rest is not favored. But the patient should stay away from heavy exertional activity, which tends to exacerbate the condition.

Generally speaking, any posture or activity that helps the patient feel better is acceptable. Symptom relief generally signals that the patient is giving the nerve root a break, giving it a chance to become less inflamed and irritated.

Physical therapy

Refer patients with lumbar radiculopathy for physical therapy, but warn the patient to avoid activities that clearly make the pain worse. The idea is to give the nerve root a break from irritation. Many patients respond well to physical therapy, particularly aquatic therapy.

If the patient’s pain is fairly severe, try a short run of corticosteroids such as a methylprednisolone dose pack followed by a course of nonsteroidal anti-inflammatory medication for several weeks.

When possible, try to avoid narcotics. However, narcotics may be necessary in severe cases for a very short course (e.g., less than two weeks). Make it clear that the narcotic dosing will be limited, and refills will not be given. If the patient remains in severe pain and is demanding refills, consider hospital admission for more aggressive and expedited management.

If the patient experiences severely intractable pain or progressive weakness in the affected muscle groups, go ahead and get non-contrast MRI of the lumbar spine. Similarly, if the patient experiences no significant improvement after 4–6 weeks of conservative management, obtain MRI for diagnostic purposes. Be aware that MRI will almost always show multiple levels of pathology, so you must look for definitive findings at the suspected level of compression.

Electromyogram (EMG) and nerve conduction velocity (NCV) evaluations seldom contribute and can be downright confusing. These exams are not recommended unless you are trying to rule out other diseases that might have signature EMG findings.

Epidural steroids or nerve root block

You may want to refer your patient to a specialist for epidural steroids or a nerve root block. These treatments won’t cure the radiculopathy, but they may help control the patient’s pain until the nerve root irritation has settled down.

Magnetic resonance imaging of the lumbar spine will be needed before the procedure. Some patients do magnificently well with one or two epidural steroid injections and can avoid surgery altogether.

Surgery

When treating a patient with radiculopathy, mild and static muscle weakness does not require urgent surgery. If the muscle weakness is rapidly progressing or severe, order an MRI and consult a spinal surgeon. Surgery should also be considered if the patient’s pain is severe and uncontrollable or is not improving over a period of conservative management (4–6 weeks). Patients who are clearly improving should not undergo surgery.

Spinal surgery can be effective in alleviating the terrible pain of lumbar radiculopathy that has not improved over time or with conservative treatment measures. Surgery is particularly effective for pain that radiates down the leg, but it is less effective for alleviating associated back pain.

Weakness may improve with surgery, sometimes markedly, but other times it doesn’t improve. Sensory symptoms are often the slowest to improve with both conservative treatments and surgical interventions, but these symptoms will eventually diminish to just a small affected area.

Simple lumbar radiculopathy can be surgically managed with a safe and limited operation involving the removal of materials compressing the affected nerve root. Nothing too extravagant is required. In almost all cases, fusion and instrumentation are not required. If a surgeon is routinely fusing and instrumenting patients with lumbar radiculopathy, steer your patients to another (and more conservative) surgeon.

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