Author(s): Casey A. Murphy, MD, James A. Forte, BS
Originally published: November 15, 2011 Last updated: July 30, 2026
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Disease/Disorder

Definition

Lumbar radiculopathy refers to a pathologic condition affecting the lumbar nerve roots. In practical terms, radiculopathy is spinal nerve-related symptoms, such as pain, with variable presence of paresthesias, weakness, reflex changes, and secondary interference of normal activities.

Etiology

Lumbar radiculopathy is usually caused by mechanical compression of nerve roots, frequently in combination with inflammatory, biochemical, and immunological insult. The most common causes include intervertebral disc herniation and spinal stenosis. Less common causes may include synovial cysts.1 Non-degenerative causes, such as neoplasms, epidural abscesses, infection, or vascular iatrogenic etiologies, can also lead to lumbar radiculopathy.2

Epidemiology including risk factors and primary prevention

The prevalence of lumbar radiculopathy is estimated to be 3-5% in the general population; 2-5% in men and 1-3% in women. The primary risk factor is age as this correlates with increasing degenerative changes to the spinal column. Men will typically experience symptoms at an earlier age than women – forties in men and fifties to sixties in women.2,3 Most cases have an atraumatic onset, and other risk factors include driving occupations, frequent lifting (especially with twisting motions), heavy industry work, direct trauma, prior history of back pain, taller height, smoking, obesity (in a dose dependent fashion3-5), sedentary lifestyle, multiple pregnancies, high workload, chronic cough, and male gender. Environmental factors are thought to account for 80% of lumbar radiculopathy onset, although a familial predisposition to lumbar herniated discs with associated lumbar radiculopathy has been reported. It should also be noted that lumbar herniated discs are not always associated with lumbar radiculopathy.3

Risk factors can be classified as modifiable and non-modifiable. Modifiable factors include smoking, obesity, occupational factors such as prolonged standing, bending, and heavy lifting. Non-modifiable factors include age, gender, and potentially socioeconomic status.6

Patho-anatomy/physiology

  • Association found between disc herniation and radiculopathy in 1934 7
  • Mechanical compression of the spinal nerve was initially presumed to be the cause of radiculopathy due to8
    • Spinal nerve anatomy poorly resistant to compression (lacking a perineurium, poorly developed epineurium, and more tenuous blood supply versus peripheral nerves)9
    • High tensile forces on the spinal nerve from tethering
    • Impaired nutrition in compressed roots
    • Intraneural edema (can directly lead to nerve injury/fibrosis or an intraneural ‘compartment syndrome’ as pressures in the spinal nerve exceeds perfusion pressures resulting in ischemia)
  • Disc injury is associated with locally increased levels of inflammatory biochemicals.
    • Increased levels of cytokines, leukotrienes, nitric oxide, immunoglobulins, interleukins, PGE-2, and metalloproteinases detected at the site of disc injury10
    • Phospholipase A2 (PLA2) levels correlate with radicular symptoms in animal models and high levels found in herniated disc material from discectomy patients
      • PLA2 also causes lumbar dorsal root ectopic discharges and evidence of demyelination11
    • Tumor necrosis factor (TNF-alpha) induces radiculopathy in animal model; TNF-alpha blockers counter this effect12
  • Immunologic factors also contribute to changes responsible for sciatica
    • Markers of glial cell and nerve damage [neurofilament (NFL), glial fibrillary acidic protein, S-100 protein, and neuron-specific enolase] were significantly elevated in the CSF of patients presenting for lumbar disc surgery compared with controls.13

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Lumbar radiculopathy caused by disc herniation has a favorable natural history in the vast majority of patients. Studies reveal that in the first 6-12 weeks, between 70 and 80% of patients had significant improvement in pain and disability with conservative management.12,14 Surgical intervention may be considered as an option when conservative management does not alleviate symptoms or in cases with significant neurologic injury. Currently, there is no consensus regarding the optimal timing for surgical intervention, as this is primarily dependent on the severity of symptoms experienced by the patient. However, a recent study monitoring patients with chronic radicular pain persisting between 4 to 12 months indicated that microdiscectomy yielded superior outcomes compared to conservative treatment at both 6 and 12 months.15 Another study monitoring postoperative pain for patients with lumbar radiculopathy who underwent discectomy surgery reported that approximately 25 – 30% of patients reported persistence of their pain following surgical intervention.16 Patients with larger disc herniations show a greater decrease in herniation size with time, which correlates with symptom improvement. 17,18

Specific secondary or associated conditions and complications

Cauda Equina Syndrome (CES): Less than 1% develop massive disc herniations that can affect the entire cauda equina with significant limb weakness and/or bowel/bladder sphincter disturbance.19 This is considered a surgical emergency as neurologic recovery correlates with timely decompression. Seventy percent of these patients develop symptoms within hours to days of onset of pain. Malignancy is another important potential cause of CES.

Progressive neurologic deficit: Single root radicular symptoms with weakness, reflex changes, neuropathic symptoms such as numbness on exam, that is progressively worsening over time is rare (~2% of cases) but also should be treated with urgent surgical treatment.20,21

Essentials of Assessment

History

Lumbar radicular pain is usually described as any combination of throbbing, aching, sharp, dull, burning, pressure, numbness, tingling, tearing, stretching or shooting symptoms. Though back pain is usually present, leg symptoms (including buttock) predominate. Symptoms most often affect the L5 or S1 nerve roots and typically follow a dermatomal pattern.15 History must include questions to rule out Cauda Equina Syndrome, progressive weakness, and “red flag” screening questions to evaluate for possible occult process: tumor, infection, fracture, inflammatory arthritis, or non-mechanical visceral diseases. Clinicians should ask for exacerbating and alleviating factors and symptom intensity, as well as precipitating factors. In auto collisions, questions would involve seatbelt usage, airbag deployment, or trajectory of vehicles. Details surrounding work injuries and pending litigation may impact prognosis in specific patient populations.

Social history includes screening for substance use and abuse, including tobacco and opiate medications. Familial history of back problems is pertinent. Asking questions to gauge how the pain impacts lifestyle, sleep, and work life is important. It is also important to note any previous exercise history.

Physical examination

  • Neurologic exam in both the upper and lower extremities: strength, reflexes, sensory testing (sacral segments if cauda equina syndrome suspected, with rectal examination). Check for both upper and lower motor neuron signs. 
  • Functional strength tests: repeated single heel lift or toe walking (S1), heel walking (L5), single leg sit to stand or squat/rise (L3, L4).
  • Root tension signs: supine straight leg raise (SLR) or Lasegue’s sign and variations, slump test, crossed SLR (low sensitivity, high specificity), femoral nerve stretch test (upper lumbar radiculopathy).
    • The straight leg raise test is more sensitive but less specific than the contralateral straight leg raise for the diagnosis of radiculopathy due to disc herniation22
  • General musculoskeletal screening and inspection to rule out soft tissue or joint pains mimicking or superimposed with radicular pain
    • Hip range of motion, hip provocative maneuvers such as flexion, adduction and internal rotation.
    • Sacroiliac joint maneuvers: (Gaenslen’s, FABER, shear tests, hip hyperextension, etc.); These tests are nonspecific and not sensitive.
    • Other diseases: screen for ischial or trochanteric bursitis, facet, IT band or knee joint dysfunction, myofascial trigger points, piriformis syndrome, plantar fasciitis

Functional assessment

Assessment of the patient’s disability using validated tools (Oswestry Disability Index, Roland Morris Disability Questionnaire [Radiculopathy version]) or query sleep quality, psychosocial stressors assessment, work/recreation ability, self-care ability.

Imaging

Imaging is indicated if symptoms have been present for more than one month, or if progressive neurologic deficit is present, medical “red flags,” exist, or there has been substantial trauma.

Radiographs, once the “first line” modality, have been found less useful in benign settings in patients under the age of 55. X-rays can be helpful in evaluating for alignment abnormalities including scoliosis and spondylolisthesis, transitional segments, and screening for fractures.

Approximately 36% of asymptomatic adults have disc herniations on lumbar magnetic resonance imaging (MRI).14 MRI is best used only as a confirmatory test of the clinical impression. MRI should be ordered prior to any spinal procedure or surgical consultation, or if symptoms fail to improve with rehabilitative care. MRI is the preferred imaging modality, though computed tomography (CT) (with or without myelography) can be considered if MRI is contraindicated or if better bony detail is required, such as in cases of prior instrumentation. According to a meta-analysis study of imaging modalities in identifying lumbar disc herniations, MRI has the highest sensitivity (89%) and specificity (83%) when compared to CT (82% and 78%) and myelography (79% and 75%).23

Supplemental assessment tools

  • Electromyography (EMG) and nerve conduction studies (NCS) can confirm clinical suspicions, identify root level, severity of involvement, acuity of injury, and evaluate other concomitant disorders when there is a lack of correlation between exam findings and imaging findings. There are drawbacks to using EMG/NCS; it can be affected and limited by pain, patients’ cooperation, temperature of room, pre-existing medical comorbidities that can produce peripheral neuropathies (diabetes, thyroid disease, renal failure), tremors, body habitus preventing full insertion of needle, and medications that produce myopathies (such as statins). There is also a subjective component of data interpretation that can change between individual clinicians.3
  • Injections, such as fluoroscopically guided transforaminal epidurals can confirm the level of radiculopathy and provide therapeutic benefit, especially where multiple disc abnormalities are seen on MRI. Caution should be taken, however, as transforaminal injections above a certain volume lose their root level selectivity.9,24 Intra-articular hip injection with local anesthetic that alleviates a majority of hip, back, thigh, and inguinal pain symptoms can confirm alternative hip pathology. Similarly, injections into other nearby structures can add diagnostic information when clinically indicated (sacroiliac, facet joint, greater trochanter, knee).25

Early predictions of outcomes

Depression, fear avoidance beliefs, and anxiety may negatively influence medical and surgical outcomes in lumbar radiculopathy patients and can be identified at initial evaluation or early follow up period using validated screening tests such as the STarT back tool, PHQ-9, FABQ, and GAD-7.

Environmental

Occupational hazards and risk factors for non-recovery must be addressed during any encounter with a patient who develops radiculopathy from a work injury. Impairment ratings, disability percentage, vocational rehabilitation, work hardening, and conditioning are all issues that can be addressed. Ergonomic adjustments should be prescribed.

Social role and social support system

Patients who take off work for long periods of time can find themselves quickly moving from the head of the household and “breadwinner” to dependent status, with loss of status and self-esteem. In these situations, the affected patient should become an active participant in their recovery program by participating in supervised exercise-based physical therapy as soon as possible. Those who miss work due to back pain for 6 months have a 50% chance of returning to work; if they are out for 1 year, there is a 25% chance of returning to work; if they are out for 2 years, then there may be close to a 0% chance of returning to work.26

Professional issues

Whenever possible, evidence-based recommendations should be considered. Prior to any procedure, informed consent must be obtained. Clinicians should be aware of the possibility of secondary gain in cases with third-party liability.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Proposed but not consensus-driven rehabilitation management emphasizes resumption and maintenance of activity.27 Short rest periods and activity modification to accommodate symptoms are recommended over bedrest. Dynamic lumbar stabilization approach includes back school and proper bending/lifting mechanics; exercise training to teach spinal stabilization (dynamic maintenance of postural control, trunk, and general upper and lower body strengthening exercises); and flexibility exercises.

At different disease stages

New onset/acute management includes3

  • General stretching program and foraminal opening maneuvers such as “McKenzie” or “MDT” (mechanical diagnosis and treatment) assessment and treatment may be of value.
  • Modalities include heat, ice, electrical stimulation, and education.
  • Correct any lateral listing (lumbar lateral shift).
  • Manipulation might be helpful in acute stages.
  • Activity modification with emphasis on staying as active as possible.
  • Medications including NSAIDs, acetaminophen, muscle relaxers, neuropathic drugs, and opioids like tramadol if needed for severe breakthrough pain only.13
  • Oral steroid tapers are often used but have not been shown to provide superior pain relief compared to placebo, and with many more side effects.28

Subacute management includes

  • Continue and advance acute care treatments as needed to assist in staying active
  • Repeat neurologic exam for new or worsening weakness
  • Dynamic lumbar stabilization program as able
  • Address any radiculopathy-related weakness with strength training
  • Epidural corticosteroid injection under fluoroscopic guidance if there is significant pain or symptoms continue to interfere with function, sleep, and employment29
  • If no improvement by 4-8 weeks, improvement plateaus over time, patient preference is for surgery, non-improving or progressive weakness, or disability is high, consider surgical consultation3
  • Interspinous Processor Decompression (IPD): An alternative to laminectomy, a lumbar interspinous spacer is intended to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate degenerative lumbar spinal stenosis; this diagnosis is typically accompanied by lumbar radiculopathy.  It is inserted using a minimally invasive procedure which leaves a full range of surgical options if revision is needed to manage return of symptoms. It can reduce the direct and indirect costs associated with lumbar stenosis and may remove or significantly delay the need for a decompressive laminectomy as well as the risk of a revision surgery associated with laminectomy.4,30 This is a viable treatment option for lumbar stenosis patients due to the lower surgical risk, rapid patient recovery, reversibility, and sustained clinical benefits. Contraindications include osteoporosis, Baastrup’s sign, and unstable spondylolisthesis greater than grade one.

Chronic/stable management

  • Complementary treatments: acupuncture or massage therapy
  • Other neuropathic agents, Transcutaneous electrical nerve stimulation (TENS) unit31
  • Spinal cord stimulation (percutaneous trial prior to implantation) if no surgical solution to neuropathic extremity pain or if patient already had surgery and has persistent pain32
  • Consideration for comprehensive multidisciplinary cognitive-behavioral pain rehabilitation program. 

Coordination of care

Coordinated practice: Physiatrist functions as “quarterback” working with patient, primary care physician, physical therapist, employer, spine surgeon, and others. The physiatrist usually serves as the interventionalist or works closely with one.

Weighing the pros and cons of surgery versus more conservative management is to be done on an individual basis. Many studies comparing surgery to conservative management favor surgery; however, the conservative management arm is not standardized in trials, and significant crossovers from each treatment arm of these studies to the other treatment arm make drawing conclusions dubious.33

Chiropractic and osteopathic manipulations may be helpful in the short term but have not been shown to provide long term relief,34 Acupuncture, massage therapy, psychology referral can be adjunctive treatments.

Patient & family education

  • Stay active, short rest periods in a position of comfort are acceptable. Hurt does not equal harm
  • Monitor for progression of weakness (< 2%)
  • Acute symptoms typically last less than 1-2 weeks
  • Lumbar radiculopathy has a favorable natural course of disease in most circumstances.
  • Recurrence rate is only approximately 8 – 12%
  • Low back pain component commonly persists
  • Epidural injections and surgery most predictably improve leg pain (not back pain)

Emerging/unique interventions

Spinal Cord Stimulation (SCS)

SCS has been a treatment for patients with chronic, intractable pain for over 40 years. The technology of these devices continues to improve at an almost yearly pace. Some of the indications for SCS include lumbar radiculopathy, failed back surgery syndrome, intractable back and leg pain, and complex regional pain syndrome.  One mechanism of conventional SCS is believed to operate on the gate theory of pain modulation. The mechanism for pain relief with conventional SCS is now known to be more complex involving both spinal and supraspinal mechanisms. Conventional SCS (tonic, low-frequency) has been shown to increase expression of inhibitory neurotransmitter GABA in the spinal cord and induce a subsequent decrease in glutamate levels in experimental animals. However, conventional SCS has limited success in treating axial back pain due to anatomic and neurophysiologic reasons. High-frequency SCS (HF-SCS) with stimulation frequencies at 10KHz and burst SCS (five-pulse train with internal frequency of 500Hz delivered at 40Hz) are thought to have their main effect on the dorsal horn of the spinal cord instead of the dorsal column.4

Lumbar Interspinous Spacer

Lumbar interspinous process decompression to treat lumbar spinal stenosis with radiculopathy was first made available in the 1980s. All three of the first-generation devices were implanted by neurosurgeons under general anesthesia. While open surgical options exist for spinal decompression, some patients do not qualify as good candidates for general anesthesia and open surgery. In 2015, the FDA approved a second generation IPD spacer. The main difference is that this surgery may be performed by an interventional pain medicine physician under moderate sedation. 5-year data from an industry sponsored study on IPD have been published showing improvements in quality of life (QOL) and pain scores.30,35 This spacer, Vertiflex, was removed from the market in 2025.

Translation into practice: Practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Thorough history and examination to rule out Cauda Equina Syndrome and other neurologic or musculoskeletal mimickers.
  • Education on favorable natural history in the face of hyperacute symptoms and importance of staying active sets the stage for effective rehabilitative management.
  • Close initial follow-up to monitor neurologic status and ensure adequate pain control with initial treatments.
  • Coordinate care early on with employer, therapist, psychologist, and interventionalist to minimize disability.

Cutting Edge/Emerging and Unique Concepts and Practice

Novel and investigational treatments include spinal injections using ultrasound guidance, and alternative epidural injectable drugs such as clonidine, anti-nerve growth factors, ozone and platelet lysate. Alternative percutaneous intradiscal treatments, such as electrothermal disc decompression, percutaneous mechanical and chemical disc decompression, and nucleoplasty have been developed. Several national twin registries are being utilized to better understand the genetic factors contributing to discogenic radiculopathy. Genetic screening for OPRM1 (genotype for Mu opioid receptor polymorphism) may predict outcomes from surgery.34 Epidural adhesiolysis for chronic neuropathic pain continues to be studied. There is a growing interest in regenerative medicine and the use of platelet rich plasma (PRP) and bone marrow concentrate (BMC) in the treatment of degenerative disc disease which can contribute to lumbar radiculopathy.36

Although TNF alpha inhibitors theoretically would work to reduce radicular pain, they are not suggested to provide benefit for the treatment of lumbar disc herniation with radiculopathy in the most recent NASS guidelines on the topic.21

Gaps in the Evidence-Based Knowledge

  • Genetic contributions to the development of radiculopathy and treatment outcomes
  • Development of effective standardized, evidence-based medical management guidelines.

References

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Original Version of the Topic

Randy Shelerud, MD. Lumbar Radiculopathy. 11/05/2011

Previous Revision(s) of the Topic

Randy Shelerud, MD Lumbar Radiculopathy. 4/8/2016

Casey A. Murphy, M.D, Randolph L. Roig, Jack Pines, M.D., and Ibrahim Samarra’e, MS-3. Lumbar Radiculopathy. 7/24/2020

Casey A. Murphy, MD, Richard Fontanez Nieves, MD Ibrahim Samarra’e, MD. Lumbar Radiculopathy. 4/20/2023

Author Disclosure

Casey A. Murphy, MD
Nothing to Disclose

James A. Forte, BS
Nothing to Disclose