Patients with radiculopathy are approached with the same treatment tools in mind as the patient with only CLBP with some important additional considerations. First, the back pain and radicular leg pain component are approached as two different problems since they can act and respond to treatments in very different ways. For instance, the back pain component does not usually respond to the treatments that are helpful for the radicular component. Treatments, such as surgical disc-ectomy, epidural steroid injections, or neuropathic drugs, can eliminate radicular leg pain, but have not shown efficacy for treating axial pain.140 Most of these patients will have a discogenic or bony hypertrophic etiology for their radicular pain. Occasionally, the radicular pain comes from a synovial cyst, but serious underlying spine disease as a source of radiculopathy is extremely rare32 and only investigated if the usual low back screening red flags are positive.
The natural history of discogenic radiculopathy is one of complete elimination of leg symptoms over time.141,142 However, someone with continued chronic and activity-limiting radicular pain can be approached with several treatment tools. The least invasive treatment options involve physical therapy combined with anlagesic oral medications. The therapy can generally consist of pain-control treatments via modalities like heat, ice, or electrical stimulation, foraminal opening maneuvers, a trial of McKenzie techniques, education on back care, sleeping positions, body mechanics, stretches, and possibly a trial of traction.143[III] As the patient progresses, typical stabilization exercise can also be introduced.
Analgesics are similar to those discussed above under Medication, with the addition of medications specific for treating neuropathic pain, such as gabapentin, pregabalin, duloxetine, tramadol, or tricyclic antidepressants. For patients who have not responded adequately to these types of treatments over time, fluoroscopically guided and contrast-controlled injections into the epidural space may add additional pain control. Empirically, patients are limited to three injections a year to avoid steroid side effects. Injections are approached one at a time and efficacy is evaluated ten days to two weeks later before any repeat injections are considered.
For patients with predominantly leg pain and continued disability despite treatments as described, a surgical consultation could be offered.
Patients with classical spinal stenosis may well have significant back pain, but they usually present because of bilateral leg pain that limits their standing and walking (pseudoclaudication). Treatments worth pursuing include a trial of flexion-biased stabilization exercises which promote a posture that opens the stenotic or narrowed spinal canal areas. This is carried out in addition to the usual back pain treatments described above under Setting up a sound treatment program. Many patients find that using a walker to allow some forward flexion while walking, increases walking tolerance significantly. Oral analgesics or epidural corticosteroid injections may be of benefit especially if there is a significant discogenic component to the stenotic area of the spinal canal. Surgery is considered an elective procedure which should ultimately be offered based on disability and lack of medical contraindications.144,145[II]
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