Clinical management of radicular pain

Abstract

This review provides an overview of the diagnosis and treatment strategies for the management of radicular pain. While it is not as common as axial spinal pain, radicular pain combines the advantage of leveraging appropriate diagnostic strategies and definitive treatments with well-informed outcome measures. Multiple diagnostic measures include not only history and physical examination, but also imaging. The treatment modalities include pharmacologic management, physical and rehabilitation measures, interventional techniques and surgical treatments. Here, the authors describe the prevalence and pathophysiology of radicular pain, risk factors, diagnostic strategies, treatment modalities and the evidence for these management strategies. Finally, the authors show the efficacy of conservative management, despite surgical management being the gold standard.

Keywords:

• cervical disc herniation
• cervical radicular pain
• cervical spondylosis
• discectomy
• epidural steroids
• fusion
• lumbar disc herniation
• lumbar radicular pain
• thoracic radicular pain

Financial & competing interests disclosure

L Manchikanti has provided limited consulting services to Semnur Pharmaceuticals, Incorporated, which is developing nonparticulate steroids. JA Hirsch is a consultant for Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

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 erroneously 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.