Lumbar Clinical Bottom Line
Based on evidence from four randomized clinical trials, no clinically important differences were demonstrated for the benefits of surgery over conservative treatment in patients with lumbar pain, clinically confirmed radiculopathy and image-confirmed disc herniation in four outcome measures: leg pain (VAS), bodily pain (SF-36), physical function (SF-36), or patient satisfaction with treatment (VAS). However, clinically important differences favoring surgery over conservative treatment were found in two outcome measures: self-report of global perceived recovery at 8 and 26 weeks post-intervention and self-report of good outcome at 1 year post-intervention. The lack of definitive evidence to support either conservative treatment or surgery for lumbar radiculopathy suggests that it may ultimately be up to the patient to choose the best course of action. Further randomized studies should incorporate a well-defined, active physical therapy intervention that is based on the best evidence to treat patients with lumbar radiculopathy as the conservative treatment. This would likely minimize cross-over to surgery and better enable determination of the most effective treatment for lumbar disc herniation.
Cervical Clinical Bottom Line
In conclusion, based on evidence from Persson et al., no clinically important difference was demonstrated for the benefits of surgery over conservative treatment in patients with clinically confirmed cervical radiculopathy pain pattern and an image confirmed disc herniation in mean current and worst pain (VAS) or patient satisfaction with outcome (Restored/Improved vs Unchanged/Worse). However, evidence from Cleland et al. does support that four variables provide the most stringent combination of predictors for identifying short-term success through non-standardized physical therapy as defined by exceeding the MCIDs of the Neck Disability Index (NDI), Patient-Specific Functional Scale (PSFS), Numeric Pain Rating Scale (NPRS), and Global Rating of Change (GROC) in those experiencing cervical radiculopathy. The four variables are age of less than 54 years, dominant arm not affected, looking down does not worsen symptoms, multimodal treatment (i.e., cervical traction, manual therapy, and deep neck flexor training) at a minimum of 50% of visits. Future randomized clinical trials with appropriate control and/or comparison group are necessary to determine the effectiveness of the multimodal physical therapy intervention in the study that was associated with increased successful patient outcomes.
After spending several rotations in outpatient orthopedic clinics as student physical therapists, we soon realized the prevalence of both cervical and lumbar radiculopathy due to disc pathology in our patients. Some of these patients were faced with the choice to continue physical therapy, as well as other conservative treatment options, or pursue surgery. Patients were often torn on which intervention to choose, as they wished to have quick resolution to their pain and return to function, but without the risks associated with surgery. As future clinicians, we wanted to determine if a surgical or physical therapy intervention was better at treating cervical and lumbar radiculopathy and providing long lasting relief from these potentially debilitating conditions.
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