Radicular pain is a difficult condition to manage. In the United Kingdom it has been suggested that the healthcare costs associated with ‘’sciatica’’ are £500 million. It is difficult to help these patients due to the intensity of the pain, high levels of disability and in some cases suicidal ideation (1).
Unsurprisingly, there is no quick fix for patients and evidence on optimal management is scarce. Nonetheless, patients seek clear and accurate explanations of the diagnosis and assistance with the condition (2). Healthcare professionals should therefore have a good understanding of the current evidence base and this blog will help you help your patients!
Part 1 of this 2-part series explored the differential diagnosis of radicular pain. In this blog, we worked through assessment, pathophysiology, causes and risk factors. It goes without saying that the treatment and management of radicular pain starts from the moment you meet your patient, not after your assessment.
By conducting a thorough assessment, listening, empathising, and seeking to understand their experience, you have laid the foundations for a strong therapeutic relationship. Creating a safe and non-judgmental environment whilst building rapport can be therapeutic for the patient and essential to their trust in you. Once your therapeutic assessment is complete, you can then continue to treat the person, not just the sciatic nerve.
Education forms a critical role in the management of radicular pain. Education may include advice regarding the diagnosis, prognosis, treatment options, reducing aggravating factors, addressing modifiable risk factors, beliefs, and anxieties. Expectations can be set regarding the prognosis which is generally favourable, but should be framed in a manner that is both optimistic yet realistic. Studies have reported that at least one-third of patients will develop persistent pain and disability lasting 1-4 years (3).
Explaining Radicular Pain
In a recent study, patients believed that mechanical compression was the sole cause of their pain and surgery is the ‘’only solution’’ (1). It is therefore vital that clinicians explain radicular pain in a manner that is individualised to the patient. This may involve using language and terminology such as the nerve root becoming ‘’crowded out’’, inflamed and sensitive.
If a patient has had a scan of their back and is concerned about the findings, it may be useful to address this in a manner that they understand. Patients may be reassured to hear that the larger the disc bulge, the more likely it is to be reabsorbed into the spinal column and that discomfort can still be experienced after this happens due to heightened sensitivity of the nerve (4). Furthermore, it is worth asking the patient to explain their understanding of the problem back to you (e.g. ‘’The Kieran O’Sullivan Test’’) so you can fill in any gaps or misunderstanding.
To learn more about how to talk with patients to help them understand their pain, check out Tom Jesson’s Masterclass on Assessing and Managing Radicular Pain.
Goal-Setting and Advice
Setting goals with patients is essential to give their radicular pain journey a direction. These should be specific to the individual and may be different depending on the acute or chronic nature of the pain. If a person is suffering from persistent symptoms, then it may be beneficial to set value-based goals and live a meaningful life with the pain, instead of seeking a cure. Self-management goals should be set with patients and exercise can be an important component of this.
Exercise and Radicular Pain
Most of the research on radicular pain investigates spinal stabilisation, motor control or neural tissue management (5). Neural tissue management addresses mechanosensitivity by including neural sliders or tensioners which can be performed independently or as manual therapy, whereas spinal stabilisation exercises typically involve McKenzie movements (patient’s preferred direction of movement).
Treatments aimed at improving motor control and reducing neural mechanosensitivity seem to be better at reducing pain compared to no or minimal treatment. However, the clinical importance of this benefit remains unclear due to the mixed quality of trials. There is no evidence that specific exercises are superior to general exercise, and therefore making recommendations is difficult (5). Nonetheless, certain patients may react better to certain interventions which emphasises the importance of individualising care (3).
Interestingly, there is some evidence to suggest that physiotherapy provides no further benefit for radicular pain compared to treatments such as ibuprofen and GP care alone (4). Certain techniques such as traction are often sold with the narrative that the traction applied to the vertebrae can increase the vertebral height, allowing space for the disc to be reabsorbed back into the spinal column. However, a Cochrane review showed no benefit of traction either alone or in combination with other treatment on pain intensity, functional status and return to work (5).
Furthermore, sometimes less is more and short periods of bed rest may be recommended as a form of therapy (6). However, this does not mean that patients should never exercise. Exercise is safe for these patients, and they should be encouraged to stay active to maintain their overall health as their pain allows. It is also worth noting that physiotherapy management is often more than just exercise and manual therapy, such as advising on return to work and informing the patient about pharmacological options (3).
To individualise your care, it is essential to educate your patient on the appropriate pharmacological options and their side effects. A recent BMJ article recommended NSAIDs and paracetamol as first-line treatment. However, if these are inadequate, antidepressant medication (e.g. amitriptyline and duloxetine) may be the next appropriate option (7).
It may be surprising for some to not see a recommendation for gabapentinoids (e.g. pregabalin and gabapentin) given their use and anecdotal reports of their benefits for acute neuropathic pain. Firstly, the NICE guidelines do not recommend their use in the management of sciatica (8):
Do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm.’
However, this conclusion is based on poor quality evidence. Much like the aforementioned physiotherapy evidence, the pharmacological evidence also has mixed trials of varying quality. Consultant physiotherapist Michelle Angus discussed here that gabapentinoids may not show an effect due to the mixed groups, some of whom did not have neuropathic pain.
The pain mechanism is important to consider when prescribing anti-neuropathic medication, which is likely different in acute and chronic populations. Furthermore, evidence shows a small benefit of gabapentinoids for individuals with true neuropathic symptoms, such as diabetic neuropathy and trigeminal neuralgia (9). Therefore, in the absence of high-quality evidence, it may be extreme to completely withhold these medications for severe neuropathic symptoms. Moreover, clinicians should use their clinical judgement when considering gabapentinoids along with their side effects and educate the patient on the current evidence base.
If conservative management in the form of education, exercise and appropriate analgesia do not improve pain and disability, then referral to specialist care for onward management may be required (3).
Epidural corticosteroid injection (ESI) is one of the most common non-surgical procedures for lumbosacral radicular pain. The aim is to inject corticosteroid directly into the epidural space to relieve pain and improve disability.
Radicular pain can be a debilitating condition and NICE guidelines recommend ESI/anaesthetic in the acute stages. A recent Cochrane review concluded that epidural corticosteroid injections were ‘’slightly more effective than placebo for leg pain and disability at short-term follow up’’ (10). Although adverse effects are small, so too is the treatment effect and the authors concluded that ESI’s may not be considered clinically significant by clinicians and patients. A 2020 systematic review concluded that ESI improves lumbosacral radicular pain at 3 and 6-months compared to conservative care (11). However, the effect was not maintained long-term and there were no differences in functional improvements.
Does this mean we remove injections from our treatment options? Based on the low-quality evidence available, it may be wise to consider them as options but inform our patients of the small effect sizes. It is worth noting that the longer symptoms persist, the less likely an injection will benefit the patient. Interestingly, if an injection has not improved someone’s pain, then it is unclear if this patient will benefit from surgery.
Lumbar microdiscectomy is the most common type of surgical procedure to relieve nerve root irritation or compression due to a herniated disc. Although the evidence is poor, two systematic reviews have shown that surgery provides a rapid decrease in pain and disability at 3 and 6-months. However, patients still report mild-to-moderate pain and disability from 1 to 2 years after surgery (12). Furthermore, physiotherapy and surgery appear to provide similar long-term outcomes (13). Irrespective of these long-term outcomes, short-term pain relief must be considered for certain individuals with acute and severe symptoms to improve quality of life.
As discussed in Tom Jesson’s Masterclass on Radicular Pain, if symptoms persist for 6 months or more, surgery may be ineffective. It is therefore vital that the clinician can educate on the role of surgery in the short, medium, and long-term and consider how appropriate the ‘’wait-and-see’’ approach is for the individual. Conservative management should remain the first-line treatment but in cases of progressive neurological deficits, persistent symptoms, and lack of response to conservative care, referral for surgical opinion is recommended (3).
To conclude on a slightly negative note, the best form of treatment appears to be prevention. While it is impossible to eliminate the chances of developing radicular pain, there are some risk factors that we can modify to potentially reduce its occurrence. This includes managing stress, improving sleep hygiene, weight management, smoking cessation, and task modification for people in manual jobs (14). Unfortunately, unlucky individuals can optimise their lifestyle and still develop radicular pain. This is when the clinician can use the evidence presented in this blog to help the patient during their radicular pain journey.