Natural History of

Radiculopathy
Ellen Casey,

MD

KEYWORDS
 Radiculopathy  Radicular pain  Natural history

Approximately two-thirds of adults suffer from neck and low back pain.1 Axial spine pain
is often accompanied by radicular pain or radiculopathy, which is defined as spinal
nerve root dysfunction causing dermatomal pain and parasthesias, myotomal weakness, and/or impaired deep tendon reflexes. Mixer and Barr first introduced the concept
of herniated disc material leading to radiculopathy in 1934.2 Since that landmark study,
extensive research has been conducted on the pathogenesis, clinical presentation, and
treatment of radiculopathy. An understanding of the natural history of radiculopathy is
crucial because it better enables health care providers to counsel patients, recommend
treatments, and assess outcomes of specific interventions. Although it can be
challenging to sort through the available information given the vast differences in diagnostic criteria, length of follow-up periods, and exposure of many patients to some type
of conservative management, this article aims to combine the findings from several
landmark papers to provide a concise summary of the natural evolution of
radiculopathy.
EPIDEMIOLOGY

The estimated prevalence of radiculopathy is 9.8 per 1000 and 3.5 cases per 1000 in the
lumbosacral and cervical spine, respectively.3,4 Patients with lumbosacral radiculopathy
tend to present in the late 1920s to 1940s, whereas the peak age of presentation for
cervical radiculopathy is in the sixth decade.5,6 Various risk factors have been
investigated for a causative role in the development of radiculopathy, including gender,
prior episodes of neck or back pain, and occupational or recreational factors. Although
some studies suggest that radiculopathy occurs more frequently in men, others have
shown equal rates between genders.57 Previous history of axial low back pain is
a well-established risk factor for lumbosacral radiculopathy, and a prior history of
lumbosacral radiculopathy has been found in patients presenting with cervical
radiculopathy. Additionally, prior history of trauma was found in approximately 15% of
cases of cervical radiculopathy but this association has not been documented in the

The author has nothing to disclose.

Sports & Spine Rehabilitation, Rehabilitation Institute of Chicago/Northwestern University
Feinberg School of Medicine, 1030 North Clark Street, Suite 500, Chicago, IL 60610, USA
E-mail address: ecasey@ric.org
Phys Med Rehabil Clin N Am 22 (2011) 15
doi:10.1016/j.pmr.2010.10.001
1047-9651/11/$ see front matter 2011 Elsevier Inc. All rights reserved.

pmr.theclinics.com

Casey

lumbar spine. Although there is a correlation between a higher body mass and low back
pain, the same relationship does not appear to exist in radiculopathy.7 Multiple studies
have shown a genetic linkage for spinal canal size as well as occurrence of disc
herniation and subsequent radiculopathy.810 In regards to occupational factors,
lumbosacral radiculopathy occurs more frequently in patients who have performed
jobs requiring manual labor, and who work in positions of sustained lumbar flexion or
rotation and who engage in prolonged driving.1113
NATURAL HISTORY
Lumbosacral Radiculopathy

The first study to follow the clinical course of patients with lumbosacral radiculopathy
was written by Hakelius14 in 1970. Of the 38 patients with a clinical presentation
consistent with radiculopathy and a disc herniation demonstrated on myelography,
88% reported that they were symptom-free after 6 months. In 1983, Weber7 published
a paper documenting a prospective study of 126 patients with sciatica. These
patients were randomized to surgery or conservative management and followed for
10 years. The primary treatment given to the 66 patients in the conservative group
was bed rest and paracetamol. Some patients also received physical therapy, but
the type and frequency was not documented. Sixty-seven percent of patients in the
conservative group reported good to fair outcomes at 1 year, 4 years and 10 years.
Saal and Saal15 conducted another prospective study that was published in 1989.
They followed 58 patients with a diagnosis of radiculopathy based on physical examination, imaging, and electrodiagnostic testing. The patients were exposed to minimal
treatment, including back school and stabilization exercises. At the conclusion of the
31-week follow-up period, 92% reported a good to excellent outcome and 92% had
returned to work. Another paper by Weber and colleagues 16 focused on the shortterm evolution of lumbosacral radiculopathy in 208 patients. These patients were
placed on bed rest for one week, and then allowed to gradually resume activity.
None of the patients underwent physical therapy. After 4 weeks, 70% of patients
had marked reduction in pain, which corresponded to functional improvement, and
60% had returned to work. Webers studies have also investigated prognostic risk
factors of recovery as well as recurrence. The factors that correlated with a poor
outcome or prolonged recovery included female gender, psychosocial problems,
greater than 3 months sick leave before presentation, and a prior history of radiculopathy. A recurrence of symptoms occurs in approximately 20% of patients.7,16
Cervical Radiculopathy

The course of clinical improvement of cervical radiculopathy is even less well documented than that of lumbosacral radiculopathy. Spurling and Segerberg17 published
one of the first papers that attempted to address this question in 1953. They followed
110 patients with cervical radiculopathy who were primarily treated with 7 to 10 days
of bed rest and traction. The average follow-up period was 23 months, and the results
showed that 77% of patients had definite improvement. They noted that in the first
month, 12% of patients were referred for surgical management, but none of the patients
that showed a response to treatment in the first month required surgery. Lees and
Turner18 conducted another early study in 1963. They followed 51 patients with cervical
spondylosis and radicular symptoms without myelopathy for 10 to 19 years. Some
patients were exposed to conservative treatments, including wearing a cervical collar
and manipulation, whereas others did not receive any treatment. At the end of the 10
years, 73% of patients reported having mild or no symptoms. DePlama and Subin19

Natural History of Radiculopathy

found significantly different results in 384 patients with cervical radiculopathy. This study
compared surgical to nonsurgical outcomes and found that only 29% of conservatively
treated patients attained complete symptom relief. Gore and colleagues20 followed
a group of 205 patients with neck pain, of whom 58% had radicular symptoms. Most
of the patients were exposed to one or more treatments, including hospitalization,
cervical collar, and oral medications. At the completion of the 10-year follow-up, 43%
were pain-free and 79% reported a reduction in symptoms. However, 32% reported
persistent moderate to severe pain. Two additional studies from the physiatry literature
suggest that 70% to 90% of patients with cervical radiculopathy have a good outcome.
However, each of these studies included some type of conservative management,
including traction.21,22 A more recent study of 563 patients who presented to the
Mayo Clinic from 1976 to 1990 also showed that 90% of patients had mild or no
symptoms after 4 to 5 years of follow-up. However, one-fifth of patients did not improve
and ultimately underwent surgical treatment.5 Only one study specifically monitored for
recurrent symptoms and found that recurrences occurred in 12.5% of patients during
a follow-up period of 1 to 2 years.22
Evolution of Radiographic Findings

The advent of computed tomography (CT) and magnetic resonance imaging (MRI) has
significantly impacted the ability to diagnose and monitor disc herniations in patients
with radiculopathy. These imaging studies have also made it possible to follow the natural
course of disc herniations and compare the morphologic changes with symptomatic
improvement. Key was the first to document the spontaneous regression of a herniated
disc in the lumbar spine by myelography in 1945.23 This phenomenon was confirmed with
the use of follow-up CT scans in the lumbar and cervical spine in 1985.24 Saal and
colleagues25 published a subsequent study in 1990 of 12 patients with documented
lumbar herniations on CT. These patients were rescanned at an average of 25 months
and the following findings were documented: 46% of subjects had 75% to 100% resorption, 36% had 50% to 75% decrease in herniation size, and 11% had 0% to 50% regression. They found that complete resorption was most frequently seen in the patients who
had the largest herniations. However, they did not find a significant correlation between
clinical and morphologic improvement. Bozzo and colleagues26 had similar results
regarding morphology of lumbar herniations on MRI: 48% of patients had greater than
70% reduction in size, 15% had a 30% to 50% reduction in size, 29% had no change,
and 8% had an increase in size. Overall, 64% of the 69 patients had a reduction in
herniation size, and the largest degree of resorption was seen in those with medium
and large herniations. Maigne and Deligne27 established a similar relationship between
greater spontaneous resolutions in larger herniations in the cervical spine. Cowan and
colleagues28 performed repeat CT scans on 106 patients one year after being diagnosed
with lumbosacral radiculopathy. Disc herniations that decreased or fully resolved were
seen in 76% of patients. However, only 26% of disc bulges decreased or resolved. Masui
and colleagues29 found that disc herniation size decreased by 95% in 21 patients who
had follow-up MRI imaging 7 to 10 years after being diagnosed with disc herniation
and radiculopathy. Cribb and colleagues30 focused on massive lumbar disc extrusions
that obscured greater than 66% of the spinal canal at the time of diagnosis of
radiculopathy. They found that after 25 months, 14 out of 15 herniations had completely
resolved. Although Komori and colleagues31 did not find a correlation between clinical
symptom and radiological improvement, this finding has been demonstrated in more
recent studies.32 Dellerud and Nakstad32 followed 92 patients over 14 months with
follow-up CT scans and found a strong association between clinical improvement and
reduction in the size of the lumbar herniation. They also found that central herniations

Casey

and disc bulges were less likely to resolve, and the reduction in size of disc bulges was
associated with a lesser degree of symptomatic improvement than with disc herniations.
SUMMARY

Radicular pain is a frequent complaint of patients presenting to outpatient primary

care and musculoskeletal clinics. Based on a review of the literature, most cases of
radiculopathy seem to be self-limiting and symptoms seem to resolve over the course
of weeks to months. Advanced imaging has demonstrated the spontaneous resolution
of disc herniations, particularly in larger protrusions and extrusions, and clinical
improvement seems to correlate with morphologic resolution. Knowledge of the
natural history of radiculopathy is crucial for the health care provider to appropriately
counsel and treat patients with this disorder. Although each patient should be
managed individually, the favorable prognosis of radiculopathy based on the natural
history supports a conservative approach for the initial weeks to months for most
patients.
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