Lumbar Radicular Pain (Sciatica)

Dimitris Papadopoulos MD Fellow Of Interventional Pain Practice (FIPP)

Updated 12 February, 2011


Lumbar radicular pain or sciatica, as most commonly known, is defined as pain induced by irritation, inflammation, pressure or injury of a lumbar spinal nerve. The pain is located in the ipsilateral lower extremity and is characterized as a sharp, stabbing, electric shock sensation.

Lumbar radicular pain has to be differentiated from lumbar radiculopathy. In radiculopathy there is sensory or/and motor loss. These two entities should not be confused. Radicular pain is a symptom induced by ectopic excitation, while radiculopathy involves also neurological processes, such as sensory or/and motor changes. The two disorders may co-exist and have the same causes, e.g. intervertebral foraminal stenosis, disc herniation, infection and other inflammatory conditions. There is also the case of patients initially suffering from radiculitis (nerve root inflammation) that later on transforms into radiculopathy.

The annual prevalence in the general population ranges from 9,9%-25%  (4) and the condition is described as “lumbar radicular pain radiating to the lower extremity below the knee”. Sciatica is the most commonly occurring neuropathic pain in the general population. The highest predispository risk factors are female gender, obesity, smoking, low back pain history, stress, depression, jobs/tasks requiring long-hour standing and frequent bending, dystocia (difficult labor), heavy weight lifting and exposure of spine to vibrations. (7)

In 60% of patients, sciatica symptoms partially or fully subside within 12 weeks from the onset of symptoms.   However, some 30% of patients keep suffering 3 months to 1 year later. The female population with chronic sciatica have worse outcome compared to men.
Lumbar Radiculopathy (Sciatica)


The most common cause of acute and subacute (6-12 weeks) lumbar radicular pain is lumbar disc herniation.
The most common cause of chronic (over 3 months) lumbar radicular pain is the formation of adhesions around some nerve root and its chronic irritation. Adhesions may form as a result of acute inflammation due to disc herniation or after  spine surgery.
Other causes of chronic radicular pain  may be: spinal canal stenosis, intervertebral foraminal stenosis (at the point where the nerve root exits), spondylolysthesis, piriformis muscle syndrome and radiculitis following radiation or chemotherapy.



Lumbar radicular pain is characterised as sharp, burning, compressive and penetrating pain  along the affected nerve pathway.  The herniation-induced pain aggravates by bending, sitting, coughing and exerting pressure on the intervetebral disc, while it improves by lying down and, probably, walking. (7) On the contrary, the pain caused by spinal canal stenosis worsens with walking and relieves with bending. (10) In addition, spinal stenosis patients develop paresthesia on the ipsilateral dermatome.

Patients suffering from chronic sciatica due to nerve root entrapment, as a result of adhesions from a previous acute inflammation or after spine surgery, very often complain about experiencing pain after sitting for a few minutes on the chair or in the car while driving. They also report that they are in pain and “get blocked” for a few minutes when getting up from the sitting position and their condition improves with walking. They feel uneasy when lying on the back and have difficulty in sleeping well.


The diagnosis of the disease is based on the history, clinical examination and supplementary tests.  The classical neurological examination includes sensory, motor and reflex examination.

The most commonly used test is the Lasegue test. The patient lies on the back and the clinician elevates the affected leg with the knee in full extension and the other leg stretched on the examination bed. Should there be pain with a leg-bed angle less than 60o when the leg elevated passively, then it is very likely that there is disc herniation and radicular inflammation. In cases of chronic radiculitis, the Lasegue test is usually negative.


1.    First symptoms occurring at the age below 20 and over 55 y.o.
2.    Constant and gradually aggravating back pain.
3.    History of malignancy
4.    Long-term use of corticosteroids
5.    Drug abuse, immunosuppression, HIV virus
6.    Unjustified body weight loss
7.    Neurological symptoms, such as muscle weakness, sensory loss, urinary or/and  defecation disorders, cauda equina syndrome
When the above symptoms occur, full and thorough investigation is essential to rule out any severe and threatening pathology and take the timely decision for surgery, when and if needed.


The most commonly used supplementary examinations are radiological evaluation, electrophysiological testing and diagnostic selective nerve root blocks. Given that 60-80% of sciatica cases recover within 6-12 weeks of conservative treatment (not necessarily with reduction of herniation size), supplementary examinations are to be conducted only when there is suspicion of a more severe primary pathology.  Radiological examinations are used mainly for ruling out other severe primary pathology, such as tumor, infection and vertebral fracture. When pain persists even three months later, MRI is the diagnostic modality of choice.


CT scan provides good information on bone structures but there are limitations with regard to soft tissues.  MRI is the diagnostic modality of choice, showing morphological changes taking place in intervertebral discs, spinal cord, nerve roots and surrounding soft tissues. (14) The diagnosis should not be based only on radiological findings, for studies have shown that approximately 30% of patients with MRI findings are asymptomatic. (16)When clinical and radiological findings match, then it is much easier to make proper diagnosis. (17,18,19)


Electrophysiological tests include nerve conduction and electromyography (EMG).  These are useful when there is suspicion for nerve defect but they do not provide any particular information regarding pain. They are also useful  for making differential diagnosis between peripheral neuropathy (e.g. piriformis muscle syndrome) and lumbar spine radiculitis. (24)


These are applied when there is doubt about which specific nerve root causes the pain. With this technique, the nerve root is blocked with 0,5ml local anaesthetic and then the patient has to report whether his/her pain impoves at least by 50%. Each suspicious nerve root is blocked separately in different sessions until the one causing the pain is identified.(23,27)



For the treatment of acute and subacute condition, anti-inflammatory drugs are recommended  but only for a short period, to avoid potential severe cardiovascular and gastrointestinal complications that might occur.(33,34)
The chronic condition is treated with drugs administered in neuropathic pain, such as antidepressants (amitriptyline), antiepileptics (carbamazepine, oxcarbazepine, gabapentin, pregabalin).
In case of resistant pain to therapy, light opioids may be added, such as codeine and tramadol.
Multifactorial rehabilitation is recommended with physical therapy and chiropractic care.
In case pain persists or the patient does not tolerate the potential adverse events of drugs s/he should be taking on a long-term basis and before deciding to administer any strong opioids, it is recommended to apply interventional pain therapies.
Before starting pharmaceutical treatment on a long-term basis, many patients choose a minimally invasive therapy which intervenes straight to the origin of pain, in order to avoid chronic addiction to drugs with several side effects.  In many cases, the ideal treatment is achieved with combination of pharmacotherapy and interventional techniques.


1.   Epidural Corticosteroid Injection(51-56)
When the disease is in its acute or subacute form, lumbar epidural corticosteroid injection is indicated. The technique used is the posterior translaminar approach and transforaminal epidural injection. The transforaminal epidural injection is more effective than the classical tranlaminar approach because the infusion of the theraupeutic drug solution is selectively targeted to the affected nerve root.  Systematic research worldwide leads to the conclusion that the lumbar epidural corticosteroid injection is significantly effective in the treatment of acute and subacute lumbar radicular pain and should always be applied before surgery decision.

2.     Neuroplasty therapy (adhesiolysis) with Racz catheter(70-83)
When the disease is in its chronic form -as usually happens after spine surgery or following the acute and subacute phase of radiculitis induced by disc herniation that had been undertreated with conservative therapy-  neuroplasty  (adhesiolysis) with Racz catheter  is indicated.
The American Society of Interventional Pain Physicians (ASIPP)  published evidence-based guidelines for interventional techniques in the management of chronic spinal pain.
According to these guidelines, there is strong evidence indicating the efficacy of neuroplasty therapy with corticosteroids in the short and long-term control of pain in refractory radiculopathy and neuropathic spinal pain.

3.  Pulsed Radiofrequency Therapy (PRF)(66,67,68,69)
In a retrospective study, Pulsed Radiofrequency was applied on lumbar dorsal root ganglia (LDRG) in a group of 13 patients who had been planned to be operated for their sciatica. Out of them, only one finally underwent discectomy and another one had spine fusion one year following the radiofrequency therapy without him experiencing radicular pain at the time of the operation.
In another retrospective study, pulsed radiofrequency was applied in sciatica patients following herniation disc, spinal canal stenosis and unsuccesful  back surgery. Significant improvement in pain and analgesic consumption was observed in patients with disc herniation and spinal canal stenosis but not to the ones who had previously been operated in the back.

4.   Spinal Cord Stimulation(84,85,86)
It is a neuromodulatory therapy, which is used in case all other less invasive methods fail. Its efficacy in treating chronic resistant neuropathic pain is significant.  According to randomized controlled studies, it is strongly supported that Spinal Cord Stimulation Therapy is more effective in the treatment of sciatica after spine surgery compared  to revision surgery.


Surgery is indicated in case of severe compression of cauda equina (last part of spinal cord) resulting in the cauda equina syndrome (CES) with permanent severe irreversible neurological defects.  In a randomized study, comparison was made between surgical and conservative treatment and it was found that there was substantial improvement in pain 3 months postoperatively.  However, one year later there was no difference between the two patient groups. A small randomized study demonstrated that there are no differences in the neurologic outcome between patients who were treated surgically or conservatively. Thus, surgical operation should be limited only to those patients whose neurological condition requires immediate nerve decompression.








1. Guyatt G, Gutterman D, Baumann MH, et al.
Grading strength of recommendations and quality of evidence
in clinical guidelines: report from an american college of chest
physicians task force. Chest. 2006;129:174–181.
2. van Kleef M, Mekhail N, van Zundert J. Evidencebased
guidelines for interventional pain medicine according to
clinical diagnoses. Pain Pract. 2009;9:247–251.
3. Dionne CE, Dunn KM, Croft PR, et al. A consensus
approach toward the standardization of back pain definitions
for use in prevalence studies. Spine. 2008;33:95–103.
4. Konstantinou K, Du nn KM. Sciatica: review of epidemiological
studies and prevalence estimates. Spine (Phila Pa
1976). 2008;33:2464–2472.
5. Khoromi S, Patsalides A, Parada S, et al. Topiramate
in chronic lumbar radicular pain. J Pain. 2005;6:829–836.
6. Dworkin RH, O’Connor AB, Backonja M, et al.
Pharmacologic management of neuropathic pain: evidencebased
recommendations. Pain. 2007;132:237–251.
7. Younes M, Bejia I, Aguir Z, et al. Prevalence and risk
factors of disk-related sciatica in an urban population in
Tunisia. Joint Bone Spine. 2006;73:538–542.
8. Weber H. The natural course of disc herniation. Acta
Orthop Scand Suppl. 1993;251:19–20.
9. Peul WC, Brand R, Thomeer RT, Koes BW. Influence
of gender and other prognostic factors on outcome of sciatica.
Pain. 2008;138:180–191.
10. Tarulli AW, Raynor EM. Lumbosacral radiculopathy.
Neurol Clin. 2007;25:387–405.
11. Murphy DR, Hurwitz EL, Gerrard JK, Clary R. Pain
patterns and descriptions in patients with radicular pain: does
the pain necessarily follow a specific dermatome? Chiropr
Osteopat. 2009;17:9.
12. Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic
value of history and physical examination in patients
suspected of sciatica due to disc herniation: a systematic
review. J Neurol. 1999;246:899–906.
13. Deville WL, van der Windt DA, Dzaferagic A,
Bezemer PD, Bouter LM. The test of Lasegue: systematic
review of the accuracy in diagnosing herniated discs. Spine.
14. Koes BW, van Tulder MW, Peul WC. Diagnosis and
treatment of sciatica. BMJ. 2007;334:1313–1317.
15. Hofstee DJ, Gijtenbeek JM, Hoogland PH, et al.
Westeinde sciatica trial: randomized controlled study of bed
rest and physiotherapy for acute sciatica. J Neurosurg.
16. Jensen MC, Brant-Zawadzki MN, Obuchowski N,
et al. Magnetic resonance imaging of the lumbar spine
in people without back pain. N Engl J Med. 1994;331:69–
17. Delauche-Cavallier MC, Budet C, Laredo JD, et al.
Lumbar disc herniation. Computed tomography scan changes
after conservative treatment of nerve root compression. Spine.
18. Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas
N. A study of computer-assisted tomography. I. The
incidence of positive CAT scans in an asymptomatic group of
patients. Spine. 1984;9:549–551.
19. Maigne JY, Rime B, Deligne B. Computed tomographic
follow-up study of forty-eight cases of nonoperatively
treated lumbar intervertebral disc herniation. Spine. 1992;
20. Modic MT, Obuchowski NA, Ross JS, et al. Acute
low back pain and radiculopathy: MR imaging findings and
their prognostic role and effect on outcome. Radiology.
21. Modic MT, Ross JS, Obuchowski NA, et al.
Contrast-enhanced MR imaging in acute lumbar radiculopathy:
a pilot study of the natural history. Radiology. 1995;
22. Tullberg T, Svanborg E, Isaccsson J, Grane P. A
preoperative and postoperative study of the accuracy and
value of electrodiagnosis in patients with lumbosacral disc
herniation. Spine. 1993;18:837–842.
23. Wolff AP, Groen GJ, Wilder-Smith OH. Influence of
needle position on lumbar segmental nerve root block selectivity.
Reg Anesth Pain Med. 2006;31:523–530.
24. Xavier AV, Farrell CE, McDanal J, Kissin I. Does
antidromic activation of nociceptors play a role in sciatic
radicular pain? Pain. 1990;40:77–79.
25. North RB, Kidd DH, Zahurak M, Piantadosi S.
Specificity of diagnostic nerve blocks: a prospective, randomized
study of sciatica due to lumbosacral spine disease. Pain.
26. Furman MB, Lee TS, Mehta A, Simon JI, Cano WG.
Contrast flow selectivity during transforaminal lumbosacral
epidural steroid injections. Pain Physician. 2008;11:855–861.
27. Wolff AP, Groen GJ, Crul BJ. Diagnostic lumbosacral
segmental nerve blocks with local anesthetics: a prospective
double-blind study on the variability and interpretation of
segmental effects. Reg Anesth Pain Med. 2001;26:147–155.
28. Wolff AP,Wilder Smith OH, Crul BJ, van de Heijden
MP, Groen GJ. Lumbar segmental nerve blocks with local
anesthetics, pain relief, and motor function: a prospective
double-blind study between lidocaine and ropivacaine. Anesth
Analg. 2004;99:496–501, table of contents.
29. Le Bars D. The whole body receptive field of dorsal
horn multireceptive neurones. Brain Res Brain Res Rev. 2002;
30. Wolff A, Wilder-Smith O. Diagnosis in patients with
chronic radiating low back pain without overt focal neurological
deficits: what is the value of segmental nerve root
blocks? Therapy. 2005;2:577–585.
31. Luijsterburg PA, Lamers LM, Verhagen AP, et al.
Cost-effectiveness of physical therapy and general practitioner
care for sciatica. Spine. 2007;32:1942–1948.
354 • van boxem et al.
32. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The
updated cochrane review of bed rest for low back pain and
sciatica. Spine. 2005;30:542–546.
33. Amlie E, Weber H, Holme I. Treatment of acute
low-back pain with piroxicam: results of a double-blind
placebo-controlled trial. Spine (Phila Pa 1976). 1987;12:473–
34. Dreiser RL, Le Parc JM, Velicitat P, Lleu PL. Oral
meloxicam is effective in acute sciatica: two randomised,
double-blind trials versus placebo or diclofenac. Inflamm Res.
2001;50(suppl 1):S17–S23.
35. Luijsterburg PA, Verhagen AP, Ostelo RW, et al.
Physical therapy plus general practitioners’ care versus general
practitioners’ care alone for sciatica: a randomised clinical
trial with a 12-month follow-up. Eur Spine J. 2008;17:509–
36. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer
DE. Long-term outcomes of surgical and nonsurgical
management of lumbar spinal stenosis: 8–10 year results
from the maine lumbar spine study. Spine. 2005;30:936–
37. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical
vs nonoperative treatment for lumbar disk herniation: the
Spine Patient Outcomes Research Trial (SPORT): a randomized
trial. JAMA. 2006;296:2441–2450.
38. Peul WC, van Houwelingen HC, van den Hout WB,
et al. Surgery versus prolonged conservative treatment for sciatica.
N Engl J Med. 2007;356:2245–2256.
39. Gibson JN, Waddell G. Surgical interventions for
lumbar disc prolapse: updated Cochrane Review. Spine.
40. Jonsson B, Stromqvist B. Clinical characteristics of
recurrent sciatica after lumbar discectomy. Spine. 1996;
41. Postacchini F, Giannicola G, Cinotti G. Recovery of
motor deficits after microdiscectomy for lumbar disc herniation.
J Bone Joint Surg Br. 2002;84:1040–1045.
42. CBO. Het Lumbosacrale radiculaire syndroom. In:
Toetsing CbvdI, ed. Consensus Richtlijnen. Utrecht: CBO;
43. Guigui P, Cardinne L, Rillardon L, et al. Per- and
postoperative complications of surgical treatment of lumbar
spinal stenosis. Prospective study of 306 patients. Rev Chir
Orthop Reparatrice Appar Mot. 2002;88:669–677.
44. Jonsson B, Stromqvist B. Motor affliction of the L5
nerve root in lumbar nerve root compression syndromes.
Spine. 1995;20:2012–2015.
45. Hahne AJ, Ford JJ. Functional restoration for a
chronic lumbar disk extrusion with associated radiculopathy.
Phys Ther. 2006;86:1668–1680.
46. Finnerup NB, Otto M, McQuay HJ, Jensen
TS, Sindrup SH. Algorithm for neuropathic pain
treatment: an evidence based proposal. Pain. 2005;118:289–
47. Saarto T, Wiffen PJ. Antidepressants for neuropathic
pain. Cochrane Database Syst Rev. 2007;4:
48. Yildirim K, Kataray S. The effectiveness of gabapentin
n patients with chronic radiculopathy. Pain Clin. 2003;
49. Dellemijn PL, van Duijn H, Vanneste JA. Prolonged
treatment with transdermal fentanyl in neuropathic pain. J
Pain Symptom Manage. 1998;16:220–229.
50. Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids
in periradicular infiltration for chronic radicular pain:
a randomized, double-blind, controlled trial. Spine. 2005;
51. McQuay HJ, Moore RA. Epidural Corticosteroids
for Sciatica. Oxford, New York, Tokyo: Oxford University
Press; 1998.
52. Koes BW, Scholten RJPM, Mens JMA, Bouter LM.
Epidural steroid injections for low back pain and sciatica: an
updated systematic review of randomized clinical trials. Pain
Digest. 1999;9:241–247.
53. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical
interventional therapies for low back pain: a review of
the evidence for an American Pain Society clinical practice
guideline. Spine (Phila Pa 1976). 2009;34:1078–1093.
54. Arden NK, Price C, Reading I, et al. A multicentre
randomized controlled trial of epidural corticosteroid injections
for sciatica: the WEST study. Rheumatology (Oxford).
55. Dilke TF, Burry HC, Grahame R. Extradural corticosteroid
injection in management of lumbar nerve root compression.
Br Med J. 1973;2:635–637.
56. Wilson-MacDonald J, Burt G, Griffin D, Glynn C.
Epidural steroid injection for nerve root compression. A randomised,
controlled trial. J Bone Joint Surg Br. 2005;87:352–
57. Carette S, Leclaire R, Marcoux S, et al. Epidural
corticosteroid injections for sciatica due to herniated nucleus
pulposus. N Engl J Med. 1997;336:1634–1640.
58. Bogduk N. Epidural steroids. Spine. 1995;20:845–
59. Riew KD, Yin Y, Gilula L, et al. The effect of nerveroot
injections on the need for operative treatment of lumbar
radicular pain. A prospective, randomized, controlled, doubleblind
study. J Bone Joint Surg Am. 2000;82-A:1589–1593.
60. Karppinen J, Malmivaara A, Kurunlahti M, et al.
Periradicular infiltration for sciatica: a randomized controlled
trial. Spine. 2001;26:1059–1067.
61. Riew KD, Park JB, Cho YS, et al. Nerve root blocks
in the treatment of lumbar radicular pain. A minimum
five-year follow-up. J Bone Joint Surg Am. 2006;88:1722–
62. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal
epidural steroid injections in lumbosacral radiculopathy:
a prospective randomized study. Spine. 2002;27:11–16.
Lumbosacral Radicular Pain • 355
63. Karppinen J, Ohinmaa A, Malmivaara A, et al. Cost
effectiveness of periradicular infiltration for sciatica: subgroup
analysis of a randomized controlled trial. Spine. 2001;
64. Ackerman WE, 3rd, Ahmad M. The efficacy of
lumbar epidural steroid injections in patients with lumbar disc
herniations. Anesth Analg. 2007;104:1217–1222, tables of
65. Thomas E, Cyteval C, Abiad L, et al. Efficacy of
transforaminal versus interspinous corticosteroid injectionin
discal radiculalgia—a prospective, randomised, double-blind
study. Clin Rheumatol. 2003;22:299–304.
66. Geurts JW, van Wijk RM, Wynne HJ, et al. Radiofrequency
lesioning of dorsal root ganglia for chronic
lumbosacral radicular pain: a randomised, double-blind, controlled
trial. Lancet. 2003;361:21–26.
67. Teixeira A, Grandinson M, Sluijter M. Pulsed radiofrequency
for radicular pain due to a herniated intervertebral
disc—an initial report. Pain Prac. 2005;5:111–115.
68. Abejon D, Garcia-del-Valle S, Fuentes ML, et al.
Pulsed radiofrequency in lumbar radicular pain: clinical
effects in various etiological groups. Pain Pract. 2007;7:21–
69. Simopoulos TT, Kraemer J, Nagda JV, Aner M,
Bajwa ZH. Response to pulsed and continuous radiofrequency
lesioning of the dorsal root ganglion and segmental nerves in
patients with chronic lumbar radicular pain. Pain Physician.
70. Heavner JE, Racz GB, Raj P. Percutaneous epidural
neuroplasty: prospective evaluation of 0.9% NaCl versus 10%
NaCl with or without hyaluronidase. Reg Anesth Pain Med.
71. Manchikanti L, Rivera JJ, Pampati V, et al. One day
lumbar epidural adhesiolysis and hypertonic saline neurolysis
in treatment of chronic low back pain: a randomized, doubleblind
trial. Pain Physician. 2004;7:177–186.
72. Veihelmann A, Devens C, Trouillier H, et al. Epidural
neuroplasty versus physiotherapy to relieve pain in patients
with sciatica: a prospective randomized blinded clinical trial. J
Orthop Sci. 2006;11:365–369.
73. Manchikanti L, Pakanati R, Bakhit CE, Pampati V.
Role of adhesiolysis and hypertonic saline neurolysis in management
of low back pain. Evaluation of modification of Racz
protocol. Pain Digest. 1999;9:91–96.
74. Gillespie G, MacKenzie P. Epiduroscopy—a review.
Scott Med J. 2004;49:79–81.
75. Boswell MV, Trescot AM, Datta S, et al. Interventional
techniques: evidence-based practice guidelines in the
management of chronic spinal pain. Pain Physician. 2007;
76. Manchikanti L, Boswell MV, Rivera JJ, et al.