Pain Practice. Volume 10 Issue 4, Pages 339 - 358

EVIDENCE-BASED MEDICINE
Evidence-Based Interventional Pain Medicine according to Clinical Diagnoses

Lumbosacral Radicular Pain

Koen Van Boxem, MD, FIPP* † ; Jianguo Cheng, MD, PhD ‡ ; Jacob Patijn, MD, PhD*; Maarten van Kleef, MD, PhD, FIPP*; Arno Lataster, MSc § ; Nagy Mekhail, MD, PhD, FIPP ‡ ; Jan Van Zundert, MD, PhD, FIPP* ¶*Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; † Department of Anesthesiology and Pain Management, Sint-Jozefkliniek, Bornem and Willebroek, Bornem, Belgium; ‡ Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, U.S.A.; § Department of Anatomy and Embryology, Maastricht University, Maastricht, the Netherlands; ¶ Department of Anesthesiology and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium. © 2010 World Institute of Pain.

ABSTRACT

Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms and/or symptoms of decreased function. The annual prevalence in the general population, described as low back pain with leg pain traveling below the knee, varied from 9.9% to 25%, which means that it is presumably the most commonly occurring form of neuropathic pain.

The patient's history may give a suggestion of lumbosacral radicular pain. The best known clinical investigation is the straight-leg raising test. Final diagnosis is made based on a combination of clinical examination and potentially additional tests. Medical imaging studies are indicated to exclude possible serious pathologies and to confirm the affected level in patients suffering lumbosacral radicular pain for longer than 3 months. Magnetic resonance imaging is preferred. Selective diagnostic blocks help confirming the affected level.

There is controversy concerning the effectiveness of conservative management (physical therapy, exercise) and pharmacological treatment.

When conservative treatment fails, in subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation, transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can be considered (2 B±), preferentially study-related.

In patients with a therapy-resistant radicular pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended (2 A+). This treatment should be performed in specialized centers.