Written By Emma Murray, June 2018
Radicular (referred) pain as a result of lumbar disc herniation is a common complaint in patients presenting to primary health-care practitioners. The estimated prevalence of lumbosacral radiculopathy (pain referring down the leg from the lower back) is 4.86-9.8 per 1000 individuals (1, 2). The natural history of lumbar radiculopathy suggests a spontaneous resolution of disc herniation with 80 and 90% of individuals showing significant improvements by six and twelve weeks, respectively (3, 4). Due to the good prognosis of lumbar radiculopathy, conservative management remains to be the first-line treatment intervention; whereby physiotherapy plays a pivotal role. Nevertheless, individual variation may deviate from this type of resolution and may require a more holistic form of healthcare intervention. Therefore, it is paramount to base individual care and intervention on sound clinical reasoning from the patient history and presentation, physical examination and diagnostic imaging to guide clinical decisions for management. However, the management of a L4 lumbar radiculopathy from a disc herniation with signs and symptoms of progressive neurological decline resulting in foot drop will encompass a much greater multi-disciplinary management approach and will be discussed in detail.
The clinical diagnosis of radiculopathy is based on pattern recognition from the patient history and physical examination to guide treatment direction and prognosis. Petersen, Laslett (5) formulated a clinical diagnostic rule (CDR) for disc herniation with nerve root involvement, however with unknown clinical utility caution is required and should be considered within the clinical picture. The clinical signs suggestive of a disc herniation with nerve root involvement are: a positive straight leg raise (SLR) test with referred leg pain, a positive crossed SLR and/or three out of four positive findings: dermatomal pain (i.e. sensation in the distribution from the nerve innervation), corresponding sensory deficits, abnormal reflexes and motor weakness (5). The diagnostic accuracy has moderate to good positive and negative likelihood ratios; however, this is based on weak methodological evidence (6). Nevertheless, a dermatomal loss with myotomal (i.e. a group of muscles that a single spinal nerve innervates) concentric ankle dorsiflexion weakness are the most clinically significant diagnostic signs of a radiculopathy (6).
The confirmation of lumbar radiculopathy through diagnostic imaging alone is seldom advantageous due to asymptomatic findings however, there is moderate sensitivity and specificity for both magnetic resonance imaging or computed tomography (7, 8). However, with clinical suspicion and worsening neurological symptoms imagining may be beneficial to identify individuals with a pathoanatomical source that may require urgent surgical consideration; in order to prevent progressive neurological dysfunction. A first contact practitioner i.e. general practitioner (GP) or physiotherapist, may refer to a radiologist for imaging to aid clinical decision. An onwards referral from the GP may be required for opinion from a neurosurgeon, neurologist or orthopaedic specialist that may require surgical intervention. This may lead down one or two paths i.e. conservative or non-conservative management or perhaps the two may run concurrently side by side based on the individual’s needs, values and preferences towards the recommended treatment options.
Best practice guidelines indicate that the first-line management for acute onset lumbar radiculopathy is education, reassurance, pain management and to maintain normal active levels; based on moderate to high quality evidence (9-12). However, relative rest to de-load sensitised neural structures from provocative postures may be advantageous initially for pain management and healing. Effective patient directed education on aetiology, prognosis and intervention options is important to decrease any misconceptions that may lead to fear avoidance behaviour, anxiety or catastrophising; which may affect patient outcomes and impact on functional recovery (13). It is also important to teach coping strategies for symptom management at home or in the workplace, and to not rely solely on passive coping strategies. Management should be considered within a biopsychosocial framework, whereby a Psychologist may help manage poor coping strategies from underlying attitudes, values and beliefs. The inclusion of a Psychologist has been shown to help prevent chronicity and has indicated better patient reported outcomes; however, the quality of evidence is low (14). The psychosocial based interventions that may be incorporated are cognitive-behavioural therapy, fear-avoidance treatment and motivational interviewing and goal setting (14).
Conservative management for lumbar radiculopathy may include exercise therapy, either supervised exercise or prescribed home exercise through a Physiotherapist; which may include directional exercises or motor control exercises; however, this is based on low quality evidence (9, 10). Functional restoration program (FRP) is another form of exercise that may facilitate natural healing of the disc through inflammatory management, postural advice and pacing strategies, alongside optimising of motor control of pelvic floor, transversus abdominis and lumbar multifidus activation exercises (15). The FRP plus advice was shown to be more effective than guideline-based advice at 10weeks and was maintained at 1year follow-up with good activity improvements however, no improvement in leg pain was reported (15). In addition, forward head posture corrective exercises in combination to the FRP had good short to long term outcomes on spinal posture in patients with chronic discogenic lumbosacral radiculopathy, however the same effectiveness may not be indicated for more acute counterparts (16). Therefore, duration of symptoms is an important consideration for exercise prescription.
The engagement of an Exercise Physiologist may help to address other morbidities and health concerns in association to the underlying primary condition. The main intervention an exercise approach would provide for the management of lumbar radiculopathy would be based on the individual’s objective findings and impairments. The addition of cardiovascular and muscular strength maintenance programs through encouragement to engage in normal activity levels and avoid bed rest is highly recommended (9, 10). Exercise therapy not only effects physical function but may improve psychological function and reported quality of life; and has been shown to do better within a multi-disciplinary biopsychosocial rehabilitation program than just usual care (14).
Other considerations for conservative management from a Physiotherapist may include spinal manipulation that has shown to have some benefit for low back pain and leg pain; with limited evidence for traction, ultrasound and low-level laser therapy as adjunctive intervention methods (10, 17). Spinal manipulation or mobilisation in the management of acute lumbar radiculopathy has been shown to have moderate level of evidence for effectiveness in treatment of symptom reduction (18). However, multiple clinical guidelines have contraindicated the use of spinal manipulation for individuals with lumbar radiculopathy; therefore, may not be considered a first line intervention method and should be based on the individuals’ presentation and response to treatment (12). The level of evidence decreases for manipulation in chronic lumbar radiculopathy with related extremity pain (18). Consequently, the duration of symptoms is an important consideration prior to implementation.
In addition, neural mobilisation for a lumbar radiculopathy may be more effective for individuals with increased neural mechanosensitivity (i.e. mechanical stress of the nerve during movement/testing) on SLR, as this has shown to be more effective in individuals with nerve root inflammation as a result of chemical irritation rather than by mechanical compression (19). This was shown in human cadaveric study whereby passive neurodynamic mobilisation exercises in the form of SLR had a significant effect in fluid dispersion around the nerve root, and therefore may be beneficial in encouraging nerve function by altering intraneural fluid accumulation (20). In the absence of mechanosensitivity a study by Scrimshaw and Maher (21) indicated that neural mobilisations did not provide additional benefit to standard postoperative management for individual’s outcomes that underwent spinal surgery. However, the indication for neural mobilisation in postoperative conservative management may not be advised due to denervation of the neural fibre rather than a mechanosenstivity. This was also supported by Schafer, Hall (22) as neural mobilisation would increase further stress to an already compressed, hypoxic and oedematous nerve root and would likely irritate the individuals’ symptoms.
The optimal duration of conservative management prior to surgical intervention has limited evidence however, some studies suggest surgery for lumbar disc herniation with radiculopathy should be performed within 4 to 8 weeks (23). Whereas, two clinical guidelines have recommended in the case of severe disabling pain for more than 6-12 weeks that has been unresponsive to conservative treatment that surgery should be advocated (17, 24).
Pain management options may encompass pharmacological intervention; however, this should not be a stand-alone treatment intervention and should be discussed within the multi-disciplinary team and be based on the individual’s needs and preferences. Management for acute lumbar radiculopathy pain from non-steroidal anti-inflammatories (NSAIDs) have been shown to be just as effective as other forms of medication with less side effects (25). However, there is low quality evidence and not clear favourable effects to support the efficacy of NSAID’s, corticosteroids and antidepressants, muscular relaxants and anticonvulsants other over management strategies (24, 26). In addition, pregabalin did not reduce leg pain associated with radiculopathy and did not improve other patient reported outcomes compared to placebo over 8-weeks and had higher reported adverse events (27). However, the pharmacological interaction may vary depending on the underlying pain mechanisms, length of duration of symptoms and interaction of other medications needs to be considered prior to prescription.
Other forms of non-conservative management include epidural steroid injections, however the benefits for lumbar radiculopathy are small and only have short-term results (17, 28). It has been shown that epidural corticosteroid injections for radiculopathy with sodium chloride solution or bupivacaine were ineffective and that lidocaine alone or with steroids were effective in the short-term (<12weeks) for relief of leg pain symptoms (29). However, a systematic review indicated based on high-quality evidence that routine use of epidural steroid injections is no more effective than injection of local anaesthetics and therefore is not recommended (30). In addition, based on clinical guidelines intravenous glucocorticosteriods for lumbar disc herniation with radiculopathy has grade ‘C’ recommendation and therefore should not be a first-line intervention (12).
It has been reported that discectomy provides faster improvement of leg pain and activity limitation compared to conservative management, however there was no difference at 1-2 years follow-up (31, 32). Another study indicated that surgical treatment for motor weakness caused by herniated intervertebral disc resulted in a rapid short-term recovery within 1month (33). Decompressive surgery has been associated with early improvement in ankle dorsiflexion weakness, however only small improvements were seen after 6-weeks with better recovery noted in younger patients with less weakness for shorter duration of symptoms (11, 34). In addition, plasma disc decompression is another form of surgery that has been suggested for younger individuals with short duration of pain that have failed conservative management with good long-term follow-up after surgery, however duration and severity of symptoms was not included (35). However, it should be mentioned that a 15-25% recurrence rate for low back pain post-lumbar discectomy for radiculopathy has been reported at 1-2 years follow-up (36). Therefore, surgery should not be considered a stand-alone treatment and should be considered within the multi-disciplinary team management.
An important consideration for lumbar radiculopathy is risk management. Risk minimisation is a principle concern in the presence of persistent neurological damage and therefore is a major focus for postoperative management. Postoperative risk management should be the combined role of a physiotherapist, occupational therapist and ergonomist dependant on the subset skills of the practitioner. The application of assistive devices or home/work modifications to minimise risk within the individual’s environment is paramount for the patient’s safety. The result of permanent neurological dysfunction leading to foot drop due to weakness in ankle dorsiflexion is the primary concern from a L4 radiculopathy. Data suggests the superiority of functional electrical stimulation compared to ankle foot orthoses on improved gait performance (37). However, the study was from a stroke induced foot drop and was limited by the level of methodological quality including research, which may not cross over for lumbar radiculopathy. Physiotherapy management alongside podiatry may assist in ankle foot orthoses, shoe advice, muscle and gait retraining.
In conclusion, the management of acute lumbar radiculopathy should encompass a multidisciplinary approach. In the presence of progressive neurological weakness and failed conservative management it is paramount to further investigate for the potential underlying cause which, may result in surgical intervention. Surgical management looks to decrease the likelihood of further permanent neurological deficits, however long-term deficits may be permanent. The management of a lumbar radiculopathy with footdrop was discussed within a multi-disciplinary management approach from conservative to non-conservative intervention strategies based on best available level of evidence.
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