Review

Clinical management of
radicular pain
Expert Rev. Neurother. Early online, 1–13 (2015)

Laxmaiah This review provides an overview of the diagnosis and treatment strategies for the
Manchikanti*1,2 and management of radicular pain. While it is not as common as axial spinal pain, radicular pain
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Joshua A Hirsch3 combines the advantage of leveraging appropriate diagnostic strategies and definitive
1
treatments with well-informed outcome measures. Multiple diagnostic measures include not
Pain Management Center of Paducah,
2831 Lone Oak Road Paducah,
only history and physical examination, but also imaging. The treatment modalities include
KY 42003, USA pharmacologic management, physical and rehabilitation measures, interventional techniques
2
University of Louisville, Louisville, and surgical treatments. Here, the authors describe the prevalence and pathophysiology of
KY, USA radicular pain, risk factors, diagnostic strategies, treatment modalities and the evidence for
3
Massachusetts General Hospital and
Harvard Medical School, Boston, these management strategies. Finally, the authors show the efficacy of conservative
MA, USA management, despite surgical management being the gold standard.
*Author for correspondence:
Tel.: +1 270 554 8373 KEYWORDS: cervical disc herniation . cervical radicular pain . cervical spondylosis . discectomy . epidural steroids
Fax: +1 270 554 8987 . fusion . lumbar disc herniation . lumbar radicular pain . thoracic radicular pain
[email protected]
For personal use only.

Since the first description of disc herniation by and around the world [7–11]. Studies by burden
Mixter and Barr in 1934 [1], voluminous litera- of disease collaborators have shown spinal pain
ture has been published describing the epidemi- occupying three of the first five categories of
ology, diagnosis and numerous treatment disability [7]. In the population-based study of
modalities available for herniated disc pain or spinal pain, the reported prevalence of regional
radiculitis. Lumbar discectomy for radicular pain was 43% in the low back, 32% in the
pain secondary to lumbar disc herniation is the neck and 13% in the thoracic spine [12].
most commonly performed procedure [2–4]. In Chronic, persistent spinal pain is reported in
contrast, cervical fusion is the most common 25–60% of patients for at least 1 year and
surgical procedure employed for patients with even longer following an initial episode [10,13].
symptomatic cervical radicular pain [5]. Several Studies on the global burden of disability have
studies have compared surgical and nonopera- estimated the point prevalence of low back
tive treatment of patients with herniated disc, pain as 9.4%, with 17% of these individuals
with often the results showing similar long- suffering from severe chronic low back pain
term outcomes, even though surgery may be and 25.8% of them suffering from severe
superior with greater improvement in select chronic low back pain with leg pain [7]. It was
patients [2–4]. The increase in the volume of spi- also shown that the point prevalence of neck
nal surgery has been shown to be dispropor- pain was estimated to be 4.9%, with a signifi-
tionate to other surgeries such as hip cant proportion of patients suffering from
replacement, knee arthroplasty and percutane- chronic neck pain and arm pain with a high
ous coronary angioplasty [6]. The present litera- disability index [8].
ture is targeted at descriptions of cervical or Thus, with the increasing prevalence and
lumbar, axial or radicular pain, and conserva- disability secondary to spinal pain, numerous
tive versus surgical management, thus providing modalities of treatment have emerged. Under-
focused reviews rather than a comprehensive standing these modalities allows one to esti-
review, which includes cervical, thoracic and mate their individual and aggregate impact on
lumbar radicular pain with the full repertoire of overall health care costs.
diagnostic and treatment strategies.
Spinal pain and the related disability have Radicular pain
been increasing exponentially with propor- Radicular pain has been discerned as the pain
tional increases in health care costs in the US perceived of as arising in a limb or trunk

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2015 Informa UK Ltd ISSN 1473-7175 1

 Review Manchikanti & Hirsch

which is caused by ectopic activation of nociceptive afferent contact of the herniated disc with the nerve root play a major
fibers in a spinal nerve or its roots or other neuropathic mecha- role, in conjunction with inflammatory components [4,18–20].
nisms [14]. Radiculitis, rather incorrectly, suggests the inflamma- The proposed etiologies in radiculitis include neural compres-
tory process as being solely responsible for the causation of sion with dysfunction, vascular compromise, inflammation and
radicular signs and symptoms. Thus, more accurately, radicular biochemical influences. Nerve injury initiates multiple events
pain is a term applied to describe pain that results from the that lead to changes in the nerve function and result in sponta-
stimulation of, or a disorder of, a nerve root. The extension of neous firing at the DRG. Risbud and Shapiro [21] described the
the terms radicular pain and radiculitis is radiculopathy, which pathophysiology of disc degeneration and pain showing that in
implies that damage to the root has produced a clinically appli- the inflammatory milieu, neurogenic factors, in particular nerve
cable motor or sensory neurological deficit in the distribution growth factor (NGF) and brain-derived neurotropic factor
of the nerve root. Consequently, radiculopathy is a disorder in (BDNF) generated by the disc and immune cells, induce an
which conduction along a nerve root is blocked, resulting in expression of pain associated with cation channels in the DRG.
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objective neurologic signs such as numbness or weakness, or in Risbud and Shapiro [21] also showed that disc degeneration is
which the blood supply to a nerve root is compromised, result- characterized by three distinct but overlapping phases in which
ing in paresthesia. Thus, the term radicular syndrome may be cytokines play a central role with an initiating event resulting
the most accurate in that it correctly suggests a constellation of in phenotypic changes and production of cytokines and chemo-
clinical signs and symptoms of variable etiologies secondary to kine by the both nucleus pulposus and annulus fibrosis cells in
pathology or dysfunction of the nerve root or dorsal root gan- the first phase, followed by further amplification of the inflam-
glia (DRG). Furthermore, radicular pain, radiculitis, radiculop- matory response by infiltrating immunocytes, as well as neovas-
athy, radicular syndrome and sciatic have been applied often cularization and nerve ingrowth into the structurally deficient
erroneously to any or all forms of pain of spinal origin per- disc tissues in the second phase. In the final phase, nerve end-
ceived in an extremity. While radicular pain in the lumbar ings are sensitized and the modulation of DRG pain channel
spine is commonly followed by pain in the cervical spine, its activity is altered by inflammatory mediators and neurotrophins
occurrence in the thoracic spine appears to be rare. resulting in pain. In addition, Olmarker et al. [22,23] showed
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In contrast to the common occurrence of spinal axial pain, that spinal nerve roots, when compressed, exhibited intraneural
the prevalence of radicular pain is uncommon with prevalence edema, deprived nutritional supply [22] and loss of amplitude of
estimates ranging between 1.2 and 43% of lumbar radiculitis nerve conduction [23]. In fact, these experimental findings were
in the general population, an annual age-adjusted incidence of confirmed by Kuslich et al. [24] who reported that noncom-
radiculopathy of 0.83% in the cervical spine, and radiculopathy pressed nerve roots did not reproduce the patient’s pain when
in the thoracic spine being uncommon [15,16]. stimulated intraoperatively in awake surgical patients.

Pathophysiology Natural history & risk factors

Lumbar radicular pain is secondary to disc herniation in >90% The natural history of radicular pain, specifically secondary to
of the cases, whereas cervical radicular pain is secondary to spon- herniated disc, has a favorable prognosis [4,10,15–20,25–31].
dylosis resulting in foraminal encroachment in 70% of Bozzao et al. [28] reported at least a 30% reduction in size of
cases [15,16]. Disc herniation is defined as a localized displacement lumbar disc herniation in 63% of the patients. Saal et al. [26].
of disc material, either nucleus pulposus and/or annulus fibrosis, reported that 90% of the patients showed good to excellent
beyond the normal margins of the intervertebral disc space, outcomes and 92% had achieved return to work status with
resulting in pain, weakness or numbness in a myotomal or der- nonoperative treatment of disc extrusions. With cervical disc
matomal distribution [4,15–20]. In contrast, spinal stenosis is herniation, in a large epidemiologic study over a 5-year follow-
defined as a narrowing of the spinal canal secondary to degenera- up period, only 31.7% of patients with symptomatic cervical
tive changes in the spinal canal, resulting in lower extremity pain radiculopathy showed symptom recurrence, whereas only 26%
and fatigue with or without back pain seen in the elderly [18]. needed surgical intervention for intractable pain, sensory deficit
Lumbar disc herniations occur in about 95% of the patients at or objective weakness [16]. Lees and Turner [27], describing the
L4/5 and L5/S1 levels in individuals aged 25–55, whereas disc natural history of cervical radiculopathy, reported that 43% of
herniation above this level is more common in people aged over patients had no further symptoms after a few months, 29%
55 years [18]. Similarly, cervical disc herniations and cervical had only mild or intermittent symptoms and only 27% had
spondylosis encroaching on the foramen occur most commonly disabling pain. However, except for the epidemiologic study for
between C5/6 and C6/7 vertebral bodies [19]. While cervical disc cervical radiculopathy [16], all studies had the limitation of
herniation occurs in the younger population with traumatic ori- small sample size.
gin and compresses the nerve roots, spondylosis is a chronic A systematic review of the literature of the course and prog-
degenerative condition in the elderly with formation of osteo- nostic factors of symptomatic cervical disc herniation with radi-
phytes [19]. Thoracic disc herniation occurs least commonly [20]. culopathy [30] with identification and review of eight articles
Even though the exact pathophysiology of radicular pain concluded that most patients with symptomatic cervical spine
continues to be unclear, local mechanical effects of direct disc herniation with radiculopathy recover. In addition, an

doi: 10.1586/14737175.2015.1048226 Expert Rev. Neurother.

 Clinical management of radicular pain Review

evidence-based clinical guideline [31] for the diagnosis and treat- that in up to 50% of the elderly without neurological disease,
ment of cervical radiculopathy from degenerative disorders con- Achilles reflexes are absent bilaterally [18,39]. However, absent or
cluded that signs and symptoms of degenerative disorders of exaggerated reflex is significant when it is associated with either
the cervical spine resulting in radiculopathy will be self-limited lower motor or upper motor neuron disease, and they are
and will resolve spontaneously over a variable length of time asymmetric. A specificity of 0.6 and a sensitivity of 0.5 have
without specific treatment. been described for Achilles reflex in diagnosing lumbar disc
An evidence-based clinical guideline for the diagnosis and herniation [40].
treatment of lumbar disc herniation with radiculopathy con- Many provocative tests have been described in the diagnosis
cluded that most patients will improve independently of treat- of cervical and lumbar radicular pain. In the cervical spine,
ment and disc herniation will often regress over time [4]. In these include neck compression test, shoulder abduction test,
addition, multiple randomized trials investigating surgical and neck distraction test, Lhermitte’s sign, Hoffmann’s sign and
nonsurgical management of herniated lumbar disc showed sig- Adson’s test [19,41]. However, these tests have been performed
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nificant improvement with nonoperative treatment. The Spine with various methods and interpretations [41]. Wainner
Patient Outcomes Research Trial (SPORT), encompassing not et al., [42], after assessing reliability and diagnostic accuracy of
only a randomized group but also an observational cohort, the clinical examination and patients’ self-report measures for
showed an overall satisfaction rate of 61.3% without surgery cervical radiculopathy, identified a cluster of four clinical signs
when two nonoperative groups were combined over time [2,3]. which included upper limb tension test A, cervical rotation,
An evidence-based clinical guideline for the diagnosis and treat- neck distraction test and Spurling test A. Of these, upper limb
ment of degenerative lumbar spinal stenosis and evidence-based tension test A was the most useful test for ruling out cervical
lumbar spinal stenosis [29] concluded that the natural history of radiculopathy. Upper limb tension test A is performed by scap-
mild to moderate degenerative lumbar spinal stenosis may be ular depression, shoulder abduction, forearm supination, wrist
favorable for 33–50% of the patients. and finger extension, shoulder lateral rotation, elbow extension,
Various literature reports describe numerous risk factors in contralateral side bending and ipsilateral cervical side bending.
causation of disc herniation and radiculitis in the lumbar spine Thus, given the paucity and complexity of evidence, the true
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compared to the cervical or thoracic spine [10,11,13,18–20]. Overall, value of clinical examination has been questioned for cervical
for neck pain, psychological factors were the leading risk factor radiculopathy [19]. However, the existing literature indicates
in all cases, followed by smoking, older age, low physical capac- high specificity, low sensitivity and good to fair interexaminer
ity, poor job satisfaction, young age for occupational injuries reliability for Spurling’s neck compression test, neck distraction
and motor vehicle injuries, and economic status, along with test and shoulder abduction (relief test). For lumbar radicular
other disorders of the spine [10,11,13,19,32–34]. pain, multiple provocative maneuvers described include very
Assessment of the risk factors for low back pain has been commonly used Lasègue’s test or Straight Leg Raising (SLR)
extensive [10,11,13,18,34–36]. Psychosocial factors, followed by test, crossed SLR, a variation of SLR test, Bowstring sign and
smoking, body mass index, social class, physical stress and job slump test. Bowstring sign and slump test are infrequently per-
satisfaction were described as important factors. formed with unknown accuracy and reliability [18,43].
The classic SLR test is considered positive when the supine
Diagnosis of radicular pain leg is elevated to between 30
and 70
and pain is reproduced
Radicular pain is diagnosed based on information obtained down to the posterior thigh below the knee. It has been shown
from multiple sources including history, physical examination to be positive in as many as 97% of the patients with surgically
encompassing neurological examination, motor examination, confirmed disc herniation [44]. However, the positive SLR is
sensory examination, reflex examination, application of provoc- less prevalent (approximately 73%) for disc herniations from
ative maneuvers and imaging. L1 to L3/4, whereas the positive rate is higher (96–98%) for
disc herniations from L4 to S1. The sensitivity of SLR has
Physical examination been shown to range from 72 to 95%, and the specificity
Physical and neurological examination provides significant ranges from 14% to as high as 66% [18]. Andersson and
information on radicular pain compared to axial spinal pain Deyo [40] reported the positive predictive value of the SLR test
with motor dysfunction, sensory dysfunction and reflex to be 67% in individuals with a great probability of having a
changes, and on the response to provocative measures. disc herniation, whereas the negative predictive value was deter-
Reflex abnormalities are the hallmark of the neurological mined to be 57%. In contrast to SLR, a cross SLR was found
examination. While absent or exaggerated reflexes by themselves to be less sensitive (23–42%) but much more specific with a
do not specify neurological disease, in patients with cervical specificity of 85–100%, with a positive predictive value of 79%
radiculitis, reflex abnormalities are seen in 70% [19]. A strong and a negative predictive value of 44% [40].
correlation has been established between reflex inhibition of the In the cervical spine, weakness has been considered to be a
biceps with C6 and the triceps with C7 [19,37,38]. However, the better and more reliable sign than numbness in one-third of
data derived from reflex abnormalities of brachioradialis are not the patients [19,37]. Biceps weakness has been reported as a very
convincing [19]. With lumbar radiculitis, it is important to note specific sign of C6 radiculopathy, even though its sensitivity is

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 Review Manchikanti & Hirsch

low, whereas triceps weakness has been found to be very sensi- vertebral canal. However, it does not demonstrate a lesion
tive for C7 radiculopathy, but has low specificity [19]. Overall, directly and it demonstrates those affecting lateral reaches of
objective motor weakness provides a diagnostic confidence the cervical spine nerves poorly [46]. In addition to myelogra-
interval of 77% for C6 radiculopathy and 67% for phy, a conventional CT scan also provides axial images in
C7 radiculopathy [19,38]. Weakness of the hand muscles is seen which the lateral reaches of the intervertebral foramina can be
only with C8 radiculopathy. Furthermore, weakness of wrist seen. CT myelography is considered to be an accurate and reli-
extensor and flexors is not a discriminating sign because it is able test and superior to myelography in the diagnosis of cervi-
seen with involvement of any of the three nerve roots – C6, cal disc protrusions. Finally, MRI is the choice of imaging in
C7 or C8. With lumbar radicular pain, weakness affects two or the modern era, replacing myelography, CT scan and com-
more muscles from the same spinal segments but different bined CT myelography. MRI is considered to be more accurate
peripheral nerves [18]. Muscle strength testing in patients with than CT, but arguably as accurate as CT myelography for
lumbar radiculopathy showed a specificity of 54% with reduced detecting cervical nerve root compression. However, the preva-
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ankle dorsiflexion, 13% with plantar flexion, with lumbar disc lence of multiple abnormalities on MRI of the cervical spine in
protrusion from L4 to S1, and had an overall specificity of asymptomatic individuals has been and remains a confounding
89% [18]. Multiple studies have reported a sensitivity as low as issue [47].
20% and a specificity as high as 99% [18]. Because of greater resolution of soft including neurologic
Sensory dysfunction is a reasonable reliable sign [38] in cervi- and interosseous tissues, MRI is considered superior to CT
cal radiculitis, even though it is a not a universal feature in scan for the demonstration of conditions such as nerve tumors,
patients with radiculopathy, with a prevalence rate varying cysts, infection and other disorders. In the assessment of lum-
from 24% to as high as 86% [37]. Numbness is most often seen bar radicular pain, some studies show the sensitivity and speci-
in C6 and C7 dermatomes. Likelihood of numbness in the ficity for plain CT, CT myelography and MRI to be the same,
C7 dermatome as diagnostic was 87%, with 73% for with an approximate sensitivity of 0.9 and specificity of
C6 dermatomal involvement. Sensory changes with lumbar rad- 0.7 and a positive and negative predictive value of 0.82 for all
iculitis have been shown to have a sensitivity of 16–66% and a three modalities, though it is not considered true in conven-
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specificity of 51–86% [18]. A sensory examination in the lower tional practice where MRI is used primarily with CT/myelogra-
extremities should cover both extremities to evaluate for all der- phy, as it is often requested by operating surgeons [48,49].
matomal or more diffuse sensory loss, as seen in the peripheral Similar to the cervical spine, in asymptomatic volunteers, a
neuropathies with a ‘stalking’ distribution of loss. A simple, yet high prevalence of disc abnormalities has been reported [50].
comprehensive sensory examination involves testing for sensa- In recent years, contrast-enhanced MRI has been shown to
tion for three dermatomes (L4, L5 and S1) in the lower demonstrate inflammatory changes surrounding the affected
extremity [18]. nerve roots. Even though MRI provides exquisite anatomic
TABLE 1 shows the features of somatic and radicular pain in detail of spinal tissues that has utility for surgical planning, it
the cervical and lumbar regions. can be of questionable value in evaluating the much larger
In the best evidence review of diagnostic procedures for neck group of patients with nonspecific low back pain [51]. Conse-
and low back pain, Rubinstein and van Tulder [45] showed that quently, multiple advanced imaging techniques have been uti-
a number of factors can be identified that can assist the clini- lized in assessing discogenic pain.
cian in identifying sciatica due to disc herniation or serious
pathology; but there was no evidence-based history leading to Electrodiagnostic studies
diagnosis not related to radicular pain. A neurological and mus- Electromyography identifies signs of denervation and muscles
culoskeletal examination may assist in the diagnosis of radiculi- innervated by the affected nerve root. The utility of electro-
tis with identification of disc herniation at various levels. TABLE 2 physiologic studies has been based on the objectification of
shows the signs and symptoms of nerve root compression at abnormalities of nerve conduction resulting from radiculopathy.
various levels in cervical and lumbar spine. They are used to identify the particular segment or in differen-
tiating a spinal lesion with spinal nerve root involvement from
Imaging the one with peripheral nerve involvement. In a consensus
Imaging has been the primary modality of investigation for spi- summary on the diagnosis and treatment of lumbar disc herni-
nal pain, especially of radiculitis. Rubinstein and van Tulder [45] ation [52], it was concluded that ‘although neurophysiologic
assessed the role of imaging as a diagnostic procedure for neck testing is frequently used to diagnose patients with radiculop-
and low back pain. They concluded that in patients 50 years of athy associated with disc herniation, these tests are not clini-
age or older, spinal radiographs with standard laboratory tests cally necessary to confirm the presence of radiculopathy’.
are highly accurate in identifying underlying systemic disease. Selective nerve root blocks and occasionally provocation discog-
Generally it is believed that plain radiography does not provide raphy have been utilized to identify the disc herniation with
any significant information in radiculitis. Myelography is an multilevel involvement after physical signs and imaging failed
invasive diagnostic test that can show the deformation pro- to delineate the level of the lesion to proceed with surgical
duced by intradural, dural and some extradural lesions of the intervention.

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 Clinical management of radicular pain Review

Diagnostic nerve blocks & discography Table 1. Features of somatic and radicular pain in cervical and lumbar
Even though there is significant literature regions.
available [13], the accuracy and value of
Somatic or referred pain Radicular pain
selective nerve root blocks and provoca-
tion discography in determining the sur- Segment Posterior segment or element Anterior segment
gical lesion and their cost–effectiveness causes
have been questioned. At the present Facet joint pain Disc herniation
time, it appears that there is no signifi- Sacroiliac joint pain Annular tear, discogenic pain
cant value for selective nerve root blocks
or provocation discography in the diag- Myofascial syndrome Spinal stenosis
nosis of radicular pain [13,53–55]. Internal disc disruption
Symptoms
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Treatment
The plethora of treatments available for Quality Dull, aching, deep Sharp, shooting, superficial,
lancinating
the management of radicular pain may
be subdivided as pharmacologic manage- Like an expanding pressure Like an electric shock
ment, physical and rehabilitation meas- Poorly localized Well localized
ures, interventional techniques and
Covers a wide area Leg worse than back
surgical treatments.
Neck and back worse than arm and Paresthesia present
Pharmacologic management leg
Patients with radicular pain are signifi- No paresthesia Well defined
cantly more likely to take drugs than those No radicular or shooting pain Radicular distribution
with axial pain only. Commonly prescribed
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drugs include NSAIDs, skeletal muscle Modification Worse with extension Worse with flexion
relaxants, opioid analgesics, benzodiaze- Better with flexion Better with extension
pines, systemic corticosteroids, antidepres-
No radicular pattern Radicular pattern
sants and anticonvulsants. There have been
multiple systematic reviews and random- Radiation Neck to head, shoulder blades, upper Follows nerve distribution
ized controlled trials (RCTs) assessing the back, radiation below the elbow
(radiation below the elbow is unusual
role of pharmacologic therapy in managing
with no radicular pain)
radicular pain; however, results are less
than encouraging [18–20,25,56–61]. Generally, Low back to hip, thigh, groin Radiation below elbow and
pharmacotherapy is considered as a treat- knee common
ment modality in the initial stages or as a Radiation below knee unusual Radicular pattern
first-line treatment; however, as a stand- Quasi-segmental
alone treatment, pharmacotherapy has not
been proven to be effective in the majority Signs
of cases of radicular pain, except in acute Sensory Uncommon Probable
episodes. Chronic drug therapy for radicu- alteration
lar pain has been shown to be ineffective, Motor Only subjective weakness Objective weakness
especially as a stand-alone treatment. In changes
selecting appropriate drugs for managing
Atrophy rare Atrophy possibly present
radicular pain, the duration and type of the
radicular symptoms are important. In the Reflex None Commonly described, but seen
acute phase, radicular pain is considered to changes only occasionally
be a predominantly nociceptive and may Provocative Only axial pain Reproduction of radicular pain
respond to NSAIDs as well as corticoste- maneuvers
roids. For chronic pain with a neuropathic No root tension signs Positive root tension signs
component, antidepressants and antiepilep-
tic agents have been considered. Many of
the medications are credited for effectiveness based on the sponta- shown low-quality evidence [56], NSAIDs have been recom-
neous recovery in the early phases of radicular pain. Even though mended as a first-line treatment for radicular pain. Chung et al.
some systematic reviews have shown variable evidence with strong [59] showed no significant difference between traditional NSAIDs
recommendation for chronic low back pain [57,59] and others have and COX-2 NSAIDs, except that traditional NSAIDs caused

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 Review Manchikanti & Hirsch

Table 2. Diagnostic features for various levels of nerve root involvement in cervical and lumbar spine.
Herniation Nerve Pain or referred pain Sensory dysfunction Motor weakness Reflexes
root and numbness
C4/5 C5 Shoulder and upper arm # Upper and lateral Shoulder muscles (deltoid– # Biceps reflex
aspect of the shoulder supraspinatus–infraspinatus)
# abduction and external
rotation
C5/6 C6 Radial aspect of forearm Radial aspect of Biceps and brachialis muscles # Thumb
forearm # flexion of the elbow and reflex and
supination brachioradialis
C6/7 C7 Dorsal aspect of forearm # Index and middle Triceps muscle # Triceps reflex
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digits # extension of the elbow

C7/T1 C8 Ulnar aspect of forearm # Ring and little digits Intrinsics of the hand No change
# adduction and abduction
L3/4 L4 Low back; hip; anterolateral Anteromedial thigh and Extension of quadriceps # Knee jerk
thigh, medial leg knee
L4/5 L5 Above S1 joint, hip; lateral thigh Lateral leg and first Dorsiflexion of great toe and None reliable
and leg; dorsum of foot three toes foot
L5/S1 S1 Above S1 joint, back, hip, Back of calf, lateral Plantar flexion of great toe # Ankle jerk
posterolateral thigh, leg and heel heel and foot, toe and foot

more side effects. Overall, NSAID use is widespread with at least antidepressants, antiepileptic drugs, corticosteroids and benzodia-
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60 million Americans regularly using them on a chronic basis [62]. zepines to improve physical as well as psychological status. How-
Consequently, complications are also extremely common; gastro- ever, the effectiveness and safety of such regimens have not been
intestinal complications have been reported in approximately 2% assessed. Extensive combination therapy has been reported for
of the users, with over 120,000 hospital admissions and over patients presenting to chronic pain management settings [65].
17,000 deaths per year just in the US alone [62].
Systematic glucocorticoid therapy is also very commonly uti- Physical & rehabilitation modalities
lized in radicular pain, especially for acute episodes. However, Many modalities of physical therapy, occupational therapy, spi-
it has been shown to be effective only on a short-term basis nal manipulation, behavioral modification, psychosocial rehabil-
with moderate quality evidence [56]. itation and multidisciplinary psychosocial rehabilitation have
The role of antiepileptic drugs, especially in chronic radiculi- been recommended. The goal of physical therapy is to increase
tis with a neuropathic component, has been stressed, but with- the range of motion and pain relief, and includes multiple
out evidence [63]. Consequently, antiepileptics enjoy extensive exercise-based approaches to strengthen supporting muscle
use, not only for widespread pain but also for radicular groups and postural support. Even though there is no high-
pain [64]. Furthermore, muscle relaxants, benzodiazepines and quality evidence for stand-alone treatment for physical therapy
antidepressants lack significant efficacy in managing radicular programs, physical therapy and exercise programs are recom-
pain, even though they may be useful in treating some muscle mended in managing cervical radicular pain [5,19,25].
spasms and underlying psychological disorders [56,57,59]. In addi- The most frequently studied forms of conservative manage-
tion, rare drugs such as anti-TNF therapy [60,61] have been uti- ment for cervical radicular pain include immobilization, trac-
lized; however, their effectiveness continues to be limited. tion, physical therapy and spinal manipulation [19,25,71–73].
Finally, opioids are the most commonly used drugs not only Cervical immobilization is used on a short-term basis for no
in chronic low back pain but also in radicular pain, encounter- longer than 1–2 weeks, and is intended to provide short-term
ing multiple adverse effects with extensive controversy and criti- pain relief sufficient for the patient to attempt other forms of
cism [56–58,65–70]. Overall, the magnitude of pain relief as well as therapy [5]. However, multiple potential disadvantages of
functional status improvement in the majority of patients with immobilization have been described, including muscle atrophy
chronic low back pain appears to be approximately 30% with after long-term use, impact on breathing and even the risk of
significant adverse consequences [70]. Even then, opioid pre- aspiration in patients using hard collars [5].
scribing continues to skyrocket despite many adverse conse- Cervical traction is also commonly used to decrease radicular
quences, with 16,235 deaths reported in the US in 2012, symptoms [25]. Traction is generally utilized in conjunction with
which is an increase of 300% since 1999 [66]. physical therapy or manipulation to distract neuroforamen, thus
In clinical settings, patients with radicular pain may receive a facilitating decompression of the nerve root and improvement of
combination of multiple drugs including NSAIDs, opioids, symptoms. However, a systematic review of mechanical traction

doi: 10.1586/14737175.2015.1048226 Expert Rev. Neurother.

 Clinical management of radicular pain Review

for neck pain with or without radicular symptoms of >3 months In managing cervical or lumbar radicular pain in clinical set-
duration was unable to form a recommendation for or against tings, exercise programs, education and multidisciplinary biop-
the use of traction due to insufficient evidence [73]. sychosocial rehabilitation have been recommended due to their
A recent systematic review and meta-analysis determining moderate effectiveness, low cost and noninvasiveness.
the level of evidence for the effectiveness of spinal manipula-
tion on cervical radicular pain reported lack of statistical differ- Interventional techniques
ences between spinal manipulation and other interventions in Interventional techniques in managing radicular pain include
their effects on reducing radicular pain, based on low-quality various types of epidural injections with or without steroids
evidence [74]. In addition, spinal manipulation of the cervical administered by three approaches which include caudal in the
spine may be associated with emergence or re-emergence of sacral region; interlaminar in the lumbar, thoracic and cervical
pain or other radicular symptoms, extremely low risk of verte- regions; and transforaminal in the lumbar region [13,75–78]. They
bral artery dissection, dural tear, phrenic nerve injury and are administered very infrequently in the thoracic and cervical
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stroke [5]. regions with a transforaminal approach. The efficacy and effec-
Cognitive behavioral therapies and multidisciplinary biopsy- tiveness of epidural injections with or without steroids in man-
chosocial rehabilitation utilized extensively for chronic low back aging radicular pain has been assessed in multiple RCTs and
pain have been studied rarely in cervical radicular pain. systematic reviews with rather divergent opinions and extensive
The numerous modalities of physical therapy and rehabilita- debate. Pinto et al. [75] assessed the role of corticosteroid injec-
tion approaches utilized in managing lumbar radicular pain tions in the management of sciatica and found a significant,
include physical therapy and exercise programs, spinal manipu- although small, effect of epidural corticosteroid injections com-
lation, massage, acupuncture, psychological therapies, cognitive pared with placebo for leg pain and disability in the short
behavioral therapies, interdisciplinary rehabilitation, functional term. The long-term effects in this systematic review were
rehabilitation and, finally, multidisciplinary biopsychosocial shown to be smaller and not statistically significant. However,
rehabilitation. These have been extensively studied in chronic their methodology has been criticized, as the authors considered
low back pain, but not as much in radicular pain [18,71]. Even local anesthetics as placebo, consequently translating active con-
For personal use only.

though exercise therapy and back schools have been shown to trol trials into placebo-controlled trials, with a meta-analysis
be only marginally superior to usual care for pain and disabil- with heterogeneous trials, leading to inaccurate conclusions [76].
ity, they have been recommended in managing radicular In contrast to Pinto et al. [75], Manchikanti et al. [76] assessed
pain [17,18,71]. Multiple other modalities including interferential epidural injections in a systematic review utilizing five levels of
therapy, low-level therapy, lumbar supports, short wave dia- evidence: Level I evidence derived from consistent findings
thermy, superficial heat, traction, transcutaneous electrical nerve among multiple high-quality RCTs, Level II evidence derived
stimulation and ultrasonography have shown no evidence of from consistent findings among multiple low-quality RCTs or
significant effectiveness [17,18,71]. Massage also has been shown one high-quality RCT, and Level III evidence derived from
to be ineffective, especially in lumbar radicular pain. Acupunc- one low-quality RCT, and other levels with inconsistent find-
ture has been found to improve pain and function for ings or lack of evidence from RCTs [79]. The results of this sys-
3–12 months in some high-quality trials [71]. Spinal manipula- tematic review [76] with inclusion of 23 RCTs of high and
tion has been rather extensively studied [71]. Cochrane reviews moderate methodologic quality in managing lumbar radicular
and other high-quality systematic reviews reached the conclu- pain showed evidence for the efficacy of all the three
sion that spinal manipulation was superior to usual care for approaches for epidural injections under fluoroscopy, with
pain and disability in managing lumbar radicular pain. Level I evidence for short-term improvement (<6 months) and
Psychological therapies with cognitive behavioral therapy were Level II evidence for long-term improvement (‡6 months). In
shown to be moderately superior to other modalities in improv- cervical radicular pain, a systematic review [77] showed Level II
ing pain; however, psychological therapies did not improve out- evidence in managing cervical radicular pain based on one
comes when added to various other noninvasive therapies [71]. high-quality RCT and three moderate-quality RCTs, with best
Interdisciplinary rehabilitation and functional restoration, evidence synthesis utilizing the five levels of evidence [79]. Simi-
especially with a cognitive behavioral component, have been lar results were echoed in comparison of various solutions uti-
shown to be more effective than usual care, that is, normal lized in epidural injections in a systematic review of RCTs [78].
activities, or standard exercise therapy for reducing time lost In this assessment, utilizing multiple high-quality RCTs, the
from work, but there is very little evidence of effectiveness of superiority of steroids was shown in managing lumbar radicular
functional restoration alone without a cognitive–behavioral pain up to 1 year of follow-up, even though the differences
component. In a Cochrane review, multidisciplinary biopsycho- were not present at 2 years of follow-up [78]. Percutaneous
social rehabilitation for chronic low back pain has been found adhesiolysis or epidural neuroplasty has not only been described
to reduce pain and disability, apart from having a positive in managing radicular pain secondary to recurrent disc hernia-
influence on work status [72]. However, this systematic tion in post lumbar surgery syndrome and spinal stenosis, but
review [72] also showed that more intensive interventions failed also in recalcitrant, chronic disc herniation as a conservative
to yield substantially superior results. management strategy [13,80]. Gerdesmeyer et al., [80], in a

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 Review Manchikanti & Hirsch

randomized, double-blind, controlled trial with an exquisite lumbar disc herniation, the results showed that the patients
design of pure placebo, have shown significant improvement in undergoing microdiscectomy had less pain in their legs and less
patients undergoing epidural neuroplasty with catheterization low back pain, but the difference was small compared to mini-
and administration of steroids, hypertonic sodium chloride mally invasive discectomy procedures. However, the evidence
solution and hyaluronidase at the end of 1 year, compared to was derived from studies utilizing small number of participants
those receiving placebo. with high risk of bias in the methodologic quality; conse-
The role of epidural injections in spinal stenosis has been quently, the overall quality of evidence was low. However, the
studied with Level II evidence with either caudal or interlami- emerging literature for minimally invasive techniques, though
nar approach in the lumbar spine [81–83]. The evidence also not abundant, shows significant improvement in well-selected
showed superiority of lumbar interlaminar epidural injections patients, specifically with contained disc herniation [4,13].
compared to caudal epidural injections, with Level III evidence
available for transforaminal epidural injections [81–84]. Further- Discectomy & fusion surgery
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more, percutaneous adhesiolysis has also been studied in spinal The evidence for assessment of the results of surgical decom-
stenosis with Level II evidence [13,85]. pression of lumbar disc herniation with radiculopathy led to a
Overall, the evidence for epidural injections in radicular pain Grade B recommendation denoting the level of evidence from
is superior to other pathologies [13,76–78]. Epidural injections a Level I study with additional supporting Level II or III stud-
also have been shown to be cost effective [86]. Furthermore, the ies or two or more consistent Level II or Level III studies [4],
consensus guidelines from British Pain Society [87] incorporate given for better medium-term symptom relief of 1–4 years
epidural injections in their management algorithm. compared with medical or interventional management of
patients with radiculopathy from lumbar disc herniations with
Minimally invasive procedures severe symptoms to warrant surgery with inclusion of the
Despite reports of the escalating use of surgical interventions SPORT trial [2,3]. However, for long-term improvement of over
along with other modalities of treatment in managing radicular 4 years, noting that a substantial portion (23–28%) of patients
pain, after appropriate physical examination, imaging findings had chronic back or leg pain, the evidence was Level IV on a
For personal use only.

and failure of conservative modalities, surgery is essential to V scale [4]. The SPORT trial, the largest and most comprehen-
relieve the pressure on the nerve root. Surgical approaches sive trial, compared surgery to medical treatment in
include multiple minimally invasive approaches such as cobla- 1244 patients included in two studies with 501 patients partici-
tion nucleoplasty for cervical, lumbar and thoracic radicular pating in an RCT [2,3]. Moderate–cost effectiveness of surgical
pain and disc herniation, and multiple other modalities, espe- discectomy was shown over a period of 2 years for lumbar disc
cially for managing lumbar radicular pain including chemo- herniation, compared to nonoperative treatment [93]. Thus, no
neurolysis, intradiscal injection of oxygen–ozone mixture, definitive conclusions can be drawn from this landmark study,
percutaneous discectomy and automated percutaneous discec- which shows that surgery may effectively relieve the pain with-
tomy [13,18–20,88]. Until recently, the literature on percutaneous out modifying the overall outcome.
disc decompression techniques suffered from lack of appropri- The results of surgical interventions in spinal stenosis have
ate RCTs [89,90]. Recently, Brouwer et al. [91] have published shown variable evidence [29]. Decompressive surgery was found to
the results of percutaneous laser disc decompression versus con- improve outcomes in patients with moderate to severe symptoms
ventional microdiscectomy in sciatica in an RCT. This nonin- of lumbar spinal stenosis with a grade of recommendation of
feriority trial of 115 surgical candidates with 53 patients in the B [29], based on multiple studies including the SPORT trial [94].
laser discectomy group and 54 patients in the surgery group In contrast to lumbar radicular pain, surgical treatment
showed similar results of laser disc decompression at 52-week options for cervical radicular pain are variable. Multiple techni-
follow-up compared to conventional surgery. Endoscopic dis- ques used in cervical radicular pain include anterior and poste-
cectomy also continues to emerge as a viable technique similar rior approaches with discectomy and fusion [5]. Results of
to other minimally invasive surgical approaches or open discec- Health Technology Assessment of cervical spine fusion for
tomy. The emerging literature shows that the most symptom- degenerative disc disease [5] identified 14 RCTs with
atic lumbar disc herniations can be successfully treated with 1209 patients. Nearly all of the studies (13 of 14) focused on
new technology, including lateral disc herniation [92]. In a patients with radicular pain with radiographic evidence of nerve
recent publication, Li et al. [92] reported 72 cases of noncon- root compression. The patients included those with disc hernia-
tained disc herniations at the L5–S1 level, which were treated tion and also spondylosis. Based on this assessment, there is
with full endoscopic discectomy. Effectiveness was shown in moderate evidence for the effectiveness of cervical spinal surgery
the majority of the patients at 12-month follow-up, with for radicular pain.
44 patients reporting excellent, 26 reporting good, one report-
ing fair and one reporting poor outcome of the total 72 cases Expert commentary
included in the study. Spinal pain and related disability have been increasing expo-
In a Cochrane review [88] of minimally invasive discectomy nentially with a resultant high economic impact [6–11]. There is
versus microdiscectomy/open discectomy for symptomatic significant debate over multiple elements of radicular pain,

doi: 10.1586/14737175.2015.1048226 Expert Rev. Neurother.

 Clinical management of radicular pain Review

including the definition, pathophysiology, risk factors and discussions continue to center around the natural history of
management strategies. Conservative management on a long- radicular pain and claims that increase of prevalence may be friv-
term basis continues to defy the expectations and shows results olous, it is a reality that many patients suffer from chronic dis-
comparable to surgical interventions [2–5,18–20,25,26,31,75–78]. Surgi- abling pain and are part of the society attempting to utilize
cal interventions are expensive and may be associated with sig- numerous divergent interventions. One of the major issues is that
nificant complications including deaths, the need for repeat this current evidence may suffer from a lack of rigor and applica-
surgery and extensive disability [6]. In fact, in an assessment of bility with small sizes of RCTs, specifically conducted in single,
spinal fusion in the US from 1998 to 2008, spinal fusion specialized centers, without appropriate outcome assessments.
increases were enormous (137%) compared to 11.3% for Furthermore, there appears to be significant variation in
laminectomy. assessment of the evidence [13,75–78,95–98] with methodologic
Consequently, radicular pain must be managed with caution quality and misunderstandings of active controlled trials com-
with appropriate history, physical examination and manage- pared to true placebo-controlled trials. It appears that evalua-
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ment strategies. Cognitive behavioral management along with tion of the evidence is highly dependent on the one who is
physical modalities and a structured exercise program appear to performing it. This can have the unfortunate consequence of
be the hallmark treatments for radicular pain, which will be misunderstanding the elements necessary for rigorous, dispas-
beneficial over a lifetime. However, those who do not respond sionate comparative effectiveness research with potentially long-
to pharmacologic and nonpharmacologic conservative manage- lasting implications of such assessment leading to inappropriate
ment must be considered for surgical interventions and, where conclusions [13,75–78,95–98].
appropriate, referral for minimally invasive approaches. The recommendations for future research include expanding
In assessing the evidence, lack of understanding of the vari- the body of evidence with rigor and clinical applicability in
ous methodological flaws in conducting and evaluating spine large RCTs conducted with clinical relevance and appropriate
research, specifically of clinical relevance, the placebo and assessment of the evidence [95,96]. Thus, our viewpoint is that
nocebo effects continues to be a major issue [95–98]. It is of cru- the field will mature over the next 5 years with further develop-
cial importance that methodologists and clinicians understand ment of high-quality evidence.
For personal use only.

the clinical and technical aspects of the interventions, along

with controlled designs. Financial & competing interests disclosure
L Manchikanti has provided limited consulting services to Semnur Phar-
Five-year view maceuticals, Incorporated, which is developing nonparticulate steroids.
As illustrated in this review, despite the high prevalence, clinical JA Hirsch is a consultant for Medtronic. The authors have no other rele-
significance and economic impact of chronic spinal pain with vant affiliations or financial involvement with any organization or entity
radicular component, the voluminous literature continues to with a financial interest in or financial conflict with the subject matter or
include numerous areas of uncertainty and debate on the man- materials discussed in the manuscript apart from those disclosed.
agement options including diagnosis and therapy. While the No writing assistance was utilized in the production of this manuscript.

Key issues
. Spinal pain and related disability are common and are increasing exponentially with proportional increases in health care costs in the US
and other parts of the world.
. Radicular pain has been described as the pain perceived of as arising in a limb or trunk which is caused by ectopic activation of
nociceptive afferent fibers in the spinal nerve or its roots or other neuropathic mechanisms. Radicular pain also has been described erro-
neously as radiculitis, radiculopathy, radicular syndrome and sciatica.
. Radicular pain is most common in the lumbar spine followed by the cervical spine and thoracic spine.
. The causes of radicular pain are disc herniation in the lumbar spine in the majority of the cases and disc herniation and spondylosis in
the cervical spine. Numerous factors have been identified led by psychosocial factors, followed by smoking, body mass index, social
class, physical stress and job satisfaction.
. Radicular pain is one of the conditions that can be diagnosed with certainty by physical examination including neurological assessment
and imaging.
. A plethora of treatment modalities have been applied in managing radicular pain, including pharmacologic, nonpharmacologic and
surgical interventions.
. The evidence for pharmacologic therapy is limited, with moderate evidence for cognitive behavioral therapy.... rehabilitation, with
epidural injections, and surgical interventions.
. Overall, there is a significant paucity of literature leading to uncertainty in many aspects of the management of radicular pain, with
significant deficiencies not only in the generation of evidence but also in understanding interpretation and inappropriate conclusions.

informahealthcare.com doi: 10.1586/14737175.2015.1048226

 Review Manchikanti & Hirsch

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