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Conservative Treatments for Lumbar Radicular Pain

  • Neuropathic Pain (E Eisenberg, Section Editor)
  • Published:
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Abstract

Lumbar radicular pain is a frequent medical pathology and represents a significant burden on society. The diagnosis of sciatica is largely clinical, in the setting of a combination of radicular pain and neurologic deficits (motor, reflexes, and/or sensation) or a positive straight leg raise test. Imaging is generally not necessary for sciatica, except in the presence of warning signs or in the setting of persisting or worsening pain. The recommended first-line treatment has not yet been clearly established. The choice of a conservative treatment approach combined with simple analgesics in the initial stages seems to be reasonable. A detailed discussion with the patient is important to explain the fact that surgery may only be necessary in the event of pain persisting in excess of 3 months or because of the development or worsening of a neurologic deficit. More high quality studies are clearly required to assist the medical practitioner in knowing how best to treat this group of patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Genevay S, Atlas SJ, Katz JN. Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review. Spine. 2010;35:803–11.

    PubMed  PubMed Central  Google Scholar 

  2. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated Cochrane review of bed rest for low back pain and sciatica. Spine. 2005;30:542–6.

    Article  PubMed  Google Scholar 

  3. Goh L, Bawendi A, Samanta J, Samanta A. An evidence-based approach to the management of low back pain and sciatica: how the evidence is applied in clinical cases. Musculoskelet Care. 2003;1:119–30.

    Article  CAS  Google Scholar 

  4. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192–300.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Awad JN, Moskovich R. Lumbar disc herniations: surgical vs nonsurgical treatment. Clin Orthop Relat Res. 2006;443:183–97.

    Article  PubMed  Google Scholar 

  6. Selim AJ, Ren XS, Fincke G, Deyo RA, Rogers W, Miller D, et al. The importance of radiating leg pain in assessing health outcomes among patients with low back pain. Results from the Veterans Health Study. Spine. 1998;23:470–4.

    Article  PubMed  CAS  Google Scholar 

  7. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010;303:1295–302.

    Article  PubMed  CAS  Google Scholar 

  8. Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine. 2008;33:2464–72.

    Article  PubMed  Google Scholar 

  9. Roncoroni C, Baillet A, Durand M, Gaudin P, Juvin R. Efficacy and tolerance of systemic steroids in sciatica: a systematic review and meta-analysis. Rheumatology. 2011;50:1603–11. Systemic steroids are often prescribed in sciatica as they are easier to deliver than Spine. injections. This study put into question their efficacy and underline the importance of their side effects.

    Article  PubMed  CAS  Google Scholar 

  10. Stafford MA, Peng P, Hill DA. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J Anaesth. 2007;99:461–73.

    Article  PubMed  CAS  Google Scholar 

  11. Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ. 2007;334:1313–7.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  12. Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14:180–91. A useful guideline to help clinicians in the treatment of lumbar radicular pain because of disc herniation. This recent and comprehensive review also underlines the lack of literature on many important questions related to the treatment of this frequent syndrome.

    Article  PubMed  Google Scholar 

  13. Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296:2441–50.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  14. Van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010. doi:10.1002/14651858.CD007431.

  15. Valat J-P, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best Pract Res Clin Rheumatol. 2010;24:241–52. A comprehensive review on both pathophysiology and treatment for lumbar radicular pain because of disc herniation.

    Article  PubMed  Google Scholar 

  16. Karjalainen U, Paananen M, Okuloff A, Taimela S, Auvinen J, Männikkö M, et al. Role of environmental factors and history of low back pain in sciatica symptoms among Finnish adolescents. Spine. 2013;38:1105–11.

    Article  PubMed  Google Scholar 

  17. Rivinoja AE, Paananen MV, Taimela SP, Solovieva S, Okuloff A, Zitting P, et al. Sports, smoking, and overweight during adolescence as predictors of sciatica in adulthood: a 28-year follow-up study of a birth cohort. Am J Epidemiol. 2011;173:890–7.

    Article  PubMed  Google Scholar 

  18. Haugen AJ, Brox JI, Grøvle L, Keller A, Natvig B, Soldal D, et al. Prognostic factors for non-success in patients with sciatica and disc herniation. BMC Musculoskelet Disord. 2012;13:183.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999;340:418–23.

    Article  PubMed  CAS  Google Scholar 

  20. Hofstee DJ, Gijtenbeek JMM, Hoogland PH, van Houwelingen HC, Kloet A, Lötters F, et al. Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. J Neurosurg. 2002;96:45–9.

    PubMed  Google Scholar 

  21. Luijsterburg PA, Verhagen AP, Ostelo RWJG, van Os AG, Peul WC, Koes BW. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J. 2007;16:881–99.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed vs advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010. doi:10.1002/14651858.CD007612.

  23. Wegner I, Widyahening IS, van Tulder MW, Blomberg SEI, de Vet HC, Brønfort G, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2013. doi:10.1002/14651858.CD003010

  24. Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der Heijden GJ, Brønfort G, Bouter LM. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2007:Issue 2. Art. No.: CD003010. doi:10.1002/14651858.CD003010

  25. Ghoname EA, White PF, Ahmed HE, Hamza MA, Craig WF, Noe CE. Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica. Pain. 1999;83:193–9.

    Article  PubMed  CAS  Google Scholar 

  26. Luijsterburg PA, Lamers LM, Verhagen AP, Ostelo RWJG, van den Hoogen HJMM, Peul WC, et al. Cost-effectiveness of physical therapy and general practitioner care for sciatica. Spine. 2007;32:1942–8.

    Article  PubMed  Google Scholar 

  27. Luijsterburg PA, Verhagen AP, Ostelo RWJG, van den Hoogen HJMM, Peul WC, Avezaat CJJ, et al. Physical therapy plus general practitioners’ care vs general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J. 2008;17:509–17.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Albert HB, Manniche C. The efficacy of systematic active conservative treatment for patients with severe sciatica: a single-blind, randomized, clinical, controlled trial. Spine. 2012;37:531–42.

    Article  PubMed  Google Scholar 

  29. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. National University of Health Sciences. J Manipulative Physiol Ther. 2010;33:576–84.

    Article  PubMed  Google Scholar 

  30. Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. Stepping up the quality of its evaluation. JAMA. 1995;274:1870–3.

    Article  PubMed  CAS  Google Scholar 

  31. Pinto RZ, Maher CG, Ferreira ML, Ferreira PH, Hancock M, Oliveira VC, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ. 2012;344:e497.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Khoromi S, Cui L, Nackers L, Max MB. Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain. Pain. 2007;130:66–75.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  33. Radcliff K, Freedman M, Hilibrand A, Isaac R, Lurie JD, Zhao W, et al. Does opioid pain medication use affect the outcome of patients with lumbar disc herniation? Spine. 2013;38:E849–60. After decades of encouragement to increase the use of opioid medications in noncancer pain, several recent publications have highlighted various problems and side effects with these treatments. This study clearly adds to our knowledge on the limitation of opioid medications in lumbar radicular pain.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Brötz D, Maschke E, Burkard S, Engel C, Mänz C, Ernemann U, et al. Is there a role for benzodiazepines in the management of lumbar disc prolapse with acute sciatica? J Pain. 2010;149:470–5.

    Article  Google Scholar 

  35. Attal N, Perrot S, Fermanian J, Bouhassira D. The neuropathic components of chronic low back pain: a prospective multicenter study using the DN4 Questionnaire. J Pain. 2011;12:1080–7. One of the only studies that clearly addresses the neuropathic component of lumbar radicular pain syndrome. A field that should deserve more attention in order to improve the current care.

    Article  PubMed  Google Scholar 

  36. Perrot S, Javier R-M, Marty M, Le Jeunne C, Laroche F. Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacologic and clinical studies. Rheumatology. 2008;47:1117–23.

    Article  PubMed  CAS  Google Scholar 

  37. Khoromi S, Patsalides A, Parada S, Salehi V, Meegan JM, Max MB. Topiramate in chronic lumbar radicular pain. J Pain. 2005;6:829–36.

    Article  PubMed  CAS  Google Scholar 

  38. Yildirim K, Sisecioglu M, Karatay S, et al. The effectiveness of gabapentin in patients with chronic radiculopathy. Pain Clin. 2003;15:213–8.

    Article  Google Scholar 

  39. Baron R, Freynhagen R, Tölle TR, Cloutier C, Leon T, Murphy TK, et al. The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy. J Pain. 2010;150:420–7.

    Article  CAS  Google Scholar 

  40. Bennett MI, Smith BH, Torrance N, Lee AJ. Can pain be more or less neuropathic? Comparison of symptom assessment tools with ratings of certainty by clinicians. Pain. 2006;122:289–94.

    Article  PubMed  Google Scholar 

  41. Finckh A, Zufferey P, Schurch M-A, Balagué F, Waldburger M, So AKL. Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial. Spine. 2006;31:377–81.

    Article  PubMed  Google Scholar 

  42. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–91.

    Article  PubMed  Google Scholar 

  43. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J. 2002;2:70–5.

    Article  PubMed  Google Scholar 

  44. Quintero N, Laffont I, Bouhmidi L, Rech C, Schneider AE, Gavardin T, et al. Transforaminal epidural steroid injection and paraplegia: case report and bibliographic review. Ann Readapt Med Phys. 2006;49:242–7.

    Article  PubMed  CAS  Google Scholar 

  45. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10:1389–94.

    Article  PubMed  Google Scholar 

  46. Wybier M, Gaudart S, Petrover D, Houdart E, Laredo J-D. Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature. Eur Radiol. 2010;20:181–9.

    Article  PubMed  Google Scholar 

  47. AFSSAPS. Risque de paraplégie/tétraplégie lié aux injections radioguidées de glucocorticoïdes au rachis lombaire ou cervical. Available at: http://ansm.sante.fr/var/ansm_site/storage/original/application/b66ab66a89c8b30fc78c334142e91b3e.pdf. Accessed 27 Aug 2014.

  48. Chang Chien GC, Candido KD, Knezevic NN. Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminal epidural steroid injection. Pain Phys. 2012;15:515–23.

    Google Scholar 

  49. Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2013. doi:10.1016/j.spinee.2013.08.049. A novative statistical method that allows a full overview of all treatments that have been tested in randomized clinical studies and their “direct” comparison. A new way to reach interesting conclusions on best available treatments.

  50. Genevay S, Finckh A, Payer M, Mezin F, Tessitore E, Gabay C, et al. Elevated levels of tumor necrosis factor-alpha in periradicular fat tissue in patients with radiculopathy from herniated disc. Spine. 2008;33:2041–6.

    Article  PubMed  CAS  Google Scholar 

  51. Pimentel DC, El Abd O, Benyamin RM, Buehler AM, Leite VF, Mazloomdoost D, et al. Anti-tumor necrosis factor antagonists in the treatment of low back pain and radiculopathy: a systematic review and meta-analysis. Pain Phys. 2014;17:E27–44.

    Google Scholar 

  52. Genevay S, Viatte S, Finckh A, Zufferey P, Balagué F, Gabay C. Adalimumab in severe and acute sciatica: a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2010;62:2339–46.

    Article  PubMed  Google Scholar 

  53. Genevay S, Finckh A, Zufferey P, Viatte S, Balagué F, Gabay C. Adalimumab in acute sciatica reduces the long-term need for surgery: a 3-year follow-up of a randomised double-blind placebo-controlled trial. Ann Rheum Dis. 2012;71:560–2.

    Article  PubMed  CAS  Google Scholar 

  54. Williams NH, Lewis R, Din NU, Matar HE, Fitzsimmons D, Phillips CJ, et al. A systematic review and meta-analysis of biological treatments targeting tumour necrosis factor α for sciatica. Eur Spine J. 2013;22:1921–35. A comprehensive analysis of the potential and the limitations of TNF inhibitors in radicular pain.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Leite VF, Buehler AM, El Abd O, Benyamin RM, Pimentel DC, Chen J, et al. Anti-nerve growth factor in the treatment of low back pain and radiculopathy: a systematic review and a meta-analysis. Pain Phys. 2014;17:E45–60.

    Google Scholar 

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Conflict of Interest

Gregory Fleury and Michael J. Nissen declare that that have no conflict of interest.

Stéphane Genevay has received an unrestricted scientific grant from Abbott.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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  1. Division of Rheumatology, University Hospitals of Geneva, 26 Avenue de Beau-Séjour, 1211, Geneva 14, Switzerland

    Gregory Fleury, Michael J. Nissen & Stéphane Genevay

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  1. Gregory Fleury
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Correspondence to Stéphane Genevay.

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This article is part of the Topical Collection on Neuropathic Pain

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Fleury, G., Nissen, M.J. & Genevay, S. Conservative Treatments for Lumbar Radicular Pain. Curr Pain Headache Rep 18, 452 (2014). https://doi.org/10.1007/s11916-014-0452-1

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  • DOI: https://doi.org/10.1007/s11916-014-0452-1

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