Acute lumbosacral radiculopathy: Treatment and prognosis
- Kerry Levin, MD
Kerry Levin, MD
- Chairman, Department of Neurology
- Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine
- Philip S Hsu, MD
Philip S Hsu, MD
- Assistant Professor
- Tufts University School of Medicine
- Carmel Armon, MD, MHS
Carmel Armon, MD, MHS
- Chairman, Department of Neurology
- Assaf Harofeh Medical Center
- Associate Clinical Professor of Neurology
- Tel Aviv University Sackler School of Medicine
Lumbosacral radiculopathy is a condition in which a disease process affects the function of one or more lumbosacral nerve roots. The most common cause is structural (ie, disc herniation or degenerative spinal stenosis) leading to root compression.
This topic will review the prognosis and treatment of lumbosacral radiculopathy, focusing on the acute period (up to four weeks). Other clinical aspects of lumbosacral radiculopathy and the management of lumbar spinal stenosis are discussed separately. (See "Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and diagnosis" and "Lumbar spinal stenosis: Treatment and prognosis".)
The management of subacute and chronic low back pain is reviewed elsewhere. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment" and "Subacute and chronic low back pain: Pharmacologic and noninterventional treatment" and "Subacute and chronic low back pain: Surgical treatment".)
For patients with acute lumbosacral radiculopathy, the objectives of treatment are to ameliorate pain (symptomatic treatment) and to address the specific underlying process (mechanism-specific treatment) if necessary (algorithm 1).
●Neoplastic or infectious etiologies of radiculopathy require prompt mechanism-specific treatment. Though rare, cauda equina syndrome represents a true surgical emergency where decompression should be performed within 24 hours, and within 12 hours if possible. (See "Treatment and prognosis of neoplastic epidural spinal cord compression, including cauda equina syndrome".)
- Serinken M, Eken C, Gungor F, et al. Comparison of Intravenous Morphine Versus Paracetamol in Sciatica: A Randomized Placebo Controlled Trial. Acad Emerg Med 2016; 23:674.
- Dreiser RL, Le Parc JM, Vélicitat P, Lleu PL. Oral meloxicam is effective in acute sciatica: two randomised, double-blind trials versus placebo or diclofenac. Inflamm Res 2001; 50 Suppl 1:S17.
- Goldie I. A clinical trial with indomethacin (indomee(R)) in low back pain and sciatica. Acta Orthop Scand 1968; 39:117.
- Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; :CD000396.
- Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine (Phila Pa 1976) 1993; 18:1433.
- Herrmann WA, Geertsen MS. Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study. Int J Clin Pract 2009; 63:1613.
- Pinto RZ, Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 2012; 344:e497.
- Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med 1999; 340:418.
- Hofstee DJ, Gijtenbeek JM, Hoogland PH, et al. Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. J Neurosurg 2002; 96:45.
- Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev 2004; :CD001254.
- Juurlink DN, Dhalla IA, Nelson LS. Improving opioid prescribing: the New York City recommendations. JAMA 2013; 309:879.
- New York City Emergency Department Discharge Opioid Prescribing Guidelines Clinical Advisory Group. New York City emergency department discharge opioid prescribing guidelines. www.nyc.gov/html/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf (Accessed on November 13, 2015).
- Finckh A, Zufferey P, Schurch MA, et al. Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial. Spine (Phila Pa 1976) 2006; 31:377.
- Haimovic IC, Beresford HR. Dexamethasone is not superior to placebo for treating lumbosacral radicular pain. Neurology 1986; 36:1593.
- Porsman O, Friis H. Prolapsed lumbar disc treated with intramuscularly administered dexamethasonephosphate. A prospectively planned, double-blind, controlled clinical trial in 52 patients. Scand J Rheumatol 1979; 8:142.
- Hedeboe J, Buhl M, Ramsing P. Effects of using dexamethasone and placebo in the treatment of prolapsed lumbar disc. Acta Neurol Scand 1982; 65:6.
- Chou R, Huffman LH, American Pain Society, American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007; 147:505.
- Friedman BW, Esses D, Solorzano C, et al. A randomized placebo-controlled trial of single-dose IM corticosteroid for radicular low back pain. Spine (Phila Pa 1976) 2008; 33:E624.
- Holve RL, Barkan H. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med 2008; 21:469.
- Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313:1915.
- Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med 2012; 157:865.
- Armon C, Argoff CE, Samuels J, et al. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007; 68:723.
- Chou R, Hashimoto R, Friedly J, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:373.
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34:1066.
- Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014; 14:180.