Kim D. Christensen, DC, DACRB, CCSP, CSCS, Kirsten Buswell, DC
Rhode Island Spine Center,
Pawtucket, RI 02860, USA.
Objective: The objective of this study was to gather descriptive information concerning the clinical outcomes of patients with cervical and lumbar radiculopathy treated with a nonsurgical, chiropractic treatment protocol in combination with other interventions.
Methods: This is a retrospective review of 162 patients with a working diagnosis of radiculopathy who met the inclusion criteria (312 consecutive patients were screened to obtain the 162 cases). Data reviewed were collected initially, during, and at the end of active treatment. The treatment protocol included chiropractic manipulation, neuromobilization, and exercise stabilization. Pain intensity was measured using the numerical pain rating scale.
Results: Of the 162 cases reviewed, 85.5% had resolution of their primary subjective radicular complaints. The treatment trial was 9 (mean) treatment sessions. The number of days between the first treatment date and the first symptom improvement was 4.2 days (median). There were 10 unresolved cases referred for epidural steroid injection, 10 unresolved cases referred for further medication management, and 3 cases referred for and underwent surgery.
Conclusion: The conservative management strategy we reviewed in our sample produced favorable outcomes for most of the patients with radiculopathy. The strategy appears to be safe. Randomized clinical trials are needed to separate treatment effectiveness from the natural history of radiculopathy.
From the FULL TEXT Article
Little is known about effective treatments for radiculopathy. Consequently, effective management strategies need to be reported and analyzed. Historically, little progress has been made in defining optimal treatment strategies because both surgical and nonsurgical approaches are commonplace. [1, 2] Useful information is lacking in regard to identifying what nonsurgical and noninvasive treatment approaches are most effective. Noninvasive treatments that follow a standardized approach, in which every patient follows a similar treatment protocol, need to be analyzed to determine if these are as effective as an approach that is individualized.
The optimal frequency and duration of nonsurgical treatment have not been properly assessed or correlated along with objective information necessary to determine when nonsurgical treatment needs to be discontinued. Because there are no clear data as to the natural history of this disorder (ie, how often a spontaneous resolution of the symptoms occurs), treatment outcomes must be analyzed with caution.
Murphy et al [3, 4] published a conservative treatment protocol that has reported effectiveness. Their nonsurgical, noninvasive treatment approach revolved around spinal manipulation, neuromobilization, and spinal stabilization exercises. Using the noninvasive approach of Murphy et al [3, 4] this review reports on the outcome of 162 consecutive patients with radiculopathy gathered retrospectively between April 2006 and April 2007 in a hospital outpatient setting.
Radiculopathy refers to those subjects with signs and symptoms related to dysfunction of the spinal nerve root(s).  It is a disorder that is painful, often disabling, and with limited information on the prevalence and incidence. In acute radiculopathy, Murphy  reports that the pain comes primarily from inflammation and compression, whereas in chronic radiculopathy, pain more often comes as a result of fibrosis. Disk herniation and lateral canal stenosis are the most common causes of radiculopathy. Disk herniation involves herniation of disk material into the intervertebral foramen. Lateral canal stenosis involves encroachment on the intervertebral foramen from osteophytes from the vertebral body or zygopophyseal joint and/or ligament flavum hypertrophy. In both cases, nerve root pain with dysfunction can occur. In addition, central canal stenosis may cause bilateral radiculopathy.
In regard to cervical radiculopathy,  the seventh cervical nerve root, between C6 and C7 (60%), and the sixth cervical nerve root, between C5 and C6 (25%), are the most commonly affected. With lumbar radiculopathy, L4, L5, and S1 are the most commonly affected nerve roots.  The diagnostic criteria for radiculopathy  are unclear. Some suggest that radiculopathy is a diagnosis based upon clinical impression that should be confirmed by advanced testing, such as diagnostic imaging or electrophysiology studies.  However, there is no criterion standard for the diagnosis of radiculopathy, as clinical, radiological, and electrophysiological testing all have inherent limitations.  The dilemma in actual fact stems from the false-positive rate associated with imaging and the false-negative rate associated with electrophysiological testing.  Given that the establishment of a criterion standard is pivotal to diagnostic accuracy, this is no minor issue.
Asymptomatic radiological abnormalities are commonly seen with advanced imaging studies.  It is accepted that the diagnostic accuracy of specialized imaging is limited, especially with regard to foraminal nerve root impingement.  Unlike electrodiagnostic testing, imaging cannot distinguish noncompressive from compressive etiologies, such as inflammation.  As a result, nerve root pain can be present in the absence of visible compression.  Thus, Rubinstein  proposes that the optimal diagnostic criterion standard should combine the findings of MRI with electrodiagnostic testing.
Advanced diagnostic testing however can be expensive and, in the case of nerve conduction studies, may be intrusive and/or painful. Clearly, there is a need for a cost-effective, accurate, and noninvasive manner for the health care provider to confirm his diagnostic impression and to determine whether the patient can be adequately treated in the primary care setting.
For the cervical spine, Rubinstein  reports that, when consistent with the history and other physical findings, a positive Spurling, neck traction, neck distraction, or Valsalva (given their high specificity) test result might be indicative of a cervical radiculopathy, whereas a negative upper limb tension test result (given its high sensitivity) might be used to rule it out.
Recently, Wainner  reported that the following cluster of cervical tests has a 90% posttest probability that the patient has cervical radiculopathy when results of all 4 tests are positive: upper-limb tension test A, Spurling test A, distraction test, and cervical rotation (<60° on ipsilateral side).
Fig 6 provides cervical orthopedic test procedures and determination of positive findings according to Cleland. 
For the sciatic nerve of the lumbar spine, Murphy  reports that the straight leg raise has good sensitivity but poor specificity. In contrast, the well leg raise has good specificity but poor sensitivity. The suggested battery of tests for sciatic radiculopathy would include the following: straight leg raise, well leg raise, Braggard dorsiflexion, and slump test. For the femoral nerve, the femoral nerve traction test  is used. The prone femoral nerve stretch tests and side-lying slump tests are then used as a battery of tests to confirm femoral involvement.  Fig 7 provides the slump and side-lying slump orthopedic test procedures and determination of positive findings according to Liebenson. 
Cleland  reports that the best clinical cluster of lumbar tests with calculated positive and negative likelihood ratios for lumbar radiculopathy include:
contralateral straight leg raise (+7.2/-.61) (well leg raise)
patellar (+7.14/-.54) and Achilles (+4.7/-.59) reflex
hip flexors weakness (+4.35/-.36)
extensor hallucis longus weakness (+4.9/-.52)
reflex/weakness/sensory all positive (+4.0/-.90)
The choice between surgical and nonsurgical treatment options remains unclear because both surgical and nonsurgical approaches are commonplace. Recently, Thomas et al  assessed the health-related quality of life after lumbar disk protrusion causing radiculopathy, as measured by the North American Spine Society neurogenic symptoms score, treated with either microdiskectomy or nonsurgical care. One-year findings demonstrated similar improvement in both treatment groups and as such were not meaningfully associated with the treatment received. Generally, nonsurgical treatment measures are attempted before invasive procedures. However, in regard to nonsurgical care, current clinical practice guidelines afford practitioners a wide spectrum of nonoperative care options, making this treatment arm difficult to standardize.
This current study is useful in that it assesses the outcome of a nonsurgical treatment approach in a hospital outpatient environment. The results of this study suggest that the combination of manipulation, neuromobilization, and stabilization exercise may be useful for patients with radiculopathy. Clinicians should consider these results when faced with decision making for individual patients.
This study does not allow one to draw conclusions about the optimum number of treatments for patients with radiculopathy. However, these patients were treated an average of 9 times. This may help the treating clinician in decision making regarding how long to continue to treat a patient with radiculopathy using this approach. This study does not support the use of a uniform number of visits automatically provided for all patients without regard for individual patient needs. It must be noted that a relatively wide range of treatments visits (eg, 1-23) was seen in this study, suggesting that individual differences in patient responses to treatment exist that necessitate greater or fewer than the mean number of treatments. Nonetheless, with a standard deviation of 5.1, these patients required between 3 and 14 visits.
According to Workers Compensation Research Institute,  lumbar radiculopathy complaints cost New York workers compensation an average per claim of $9847.00 and cervical radiculopathy $11,191.00 per claim. With our mean treatment number to resolve radiculopathy (costs less than $1500.00), it is clearly less expensive than customary treatment costs in New York.
This study demonstrated a decrease in the numeric rating scale within 8 days. If this is not seen, it may suggest the need for a surgical consultation. In addition, a change of 2 points on the NRS is generally considered to be the threshold for clinically meaningful improvement.  The change (median) between initial and final score in this study was 4.2. Thus, if a minimum improvement of 2 points on the NRS is not seen, further nonsurgical treatment may not be appropriate.
It is difficult to compare the results presented here with those of other studies on nonsurgical management of patients with radiculopathy owing to difference in design, outcome measurement, and selection criteria. Interesting to note, in this study, there was no emphasis on “end-range loading” passive/active exercise techniques. This study however used neutral spine stabilization.
Controversy exists over the use of manipulation in patients with radiculopathy. It has been stated that this treatment is contraindicated in the presence of a herniated disk.  No major complication was seen in any of these patients. The data presented here would continue to suggest that manipulation, when applied by properly trained and experience practitioners, is potentially a safe option for patients with radiculopathy.
Radiographic biomechanical analysis was performed on all patients to determine deviations from neutral to position the patient for manipulation and neuromobilization procedures. Fig 8 demonstrates the lower extremity neuromobilization positions used that were based upon the radiographic findings noted. Randomized clinical trials are needed to document any actual improved outcomes with this use.
Fig. 8: Neuromobilization positions with lumbar centration.
There are several important limitations to this study. It is not a randomized controlled trial; thus, interpretation of the results must be made with caution. The natural history of radiculopathy is generally thought to be favorable; however, data on untreated patients with this disorder are lacking. Because of this scarcity of natural history data and because the current study did not involve an untreated or placebo control group and there was no long-term follow-up, there is no way to compare the outcomes reported here with those in the untreated situation. Numerical pain rating has 1 major setback in terms of validity, which is that indeterminate factors such as patient mood, attitude, central and/or peripheral sensitization, and other biopsychosocial factors can play a role in pain reporting. Palpation of restricted spinal segments has been repeatedly shown to have relatively weak intra-/interexaminer reliability. It is possible that only one of the treatments discussed or any combination of the treatments produced the positive results seen.
The current study supports the notion that chiropractic management and nonsurgical measures are a viable alternative to surgery in patients with radiculopathy. Randomized controlled trials are called for to further assess this nonsurgical approach compared with untreated controls and surgical treatments.