Radiculopathy - Cervical and Lumbar

DIAGNOSIS: Radiculopathy - Cervical and Lumbar ICD-10: M54.10 (Radiculopathy, site unspecified); M54.12 (Radiculopathy, cervical region); M54.13 (Radiculopathy, cervicothoracic region); M54.16 (Radiculopathy, lumbar region); M54.17 (Radiculopathy, lumbosacral region); G55 (Nerve root and plexus compressions in diseases classified elsewhere); M50.10 (Cervical disc disorder with radiculopathy, unspecified); M51.16 (Intervertebral disc disorders with radiculopathy, lumbar region)

CPT CODES: 85025 (CBC with differential), 80053 (CMP - BMP + LFTs), 85652 (ESR), 86140 (CRP), 83036 (HbA1c), 82947 (Fasting glucose), 82607 (Vitamin B12), 84443 (TSH), 86812 (HLA-B27), 81001 (Urinalysis), 84153 (PSA - males >50), 87040 (Blood cultures x2), 86335 (SPEP with immunofixation), 86334 (SPEP with immunofixation), 86618 (Lyme serology), 86255 (Paraneoplastic panel), 86038 (ANA), 82164 (ACE level), 72141 (MRI spine without contrast - cervical), 72156 (MRI spine with and without contrast - cervical), 72050 (X-ray spine AP/lateral, flexion/extension - cervical), 72132 (CT myelogram), 95886 (EMG/NCS - electrodiagnostic studies), 95909 (EMG/NCS - electrodiagnostic studies), 78300 (Bone scan - nuclear), 78816 (PET-CT), 62290 (Discography) SYNONYMS: Radiculopathy, pinched nerve, nerve root compression, cervical radiculopathy, lumbar radiculopathy, sciatica, brachialgia, cervical disc herniation with radiculopathy, lumbar disc herniation with radiculopathy, foraminal stenosis, nerve root impingement, radicular pain, dermatomal pain, nerve root syndrome SCOPE: Evaluation and management of cervical (C5-T1) and lumbar (L2-S1) radiculopathy in adults. Covers red flag identification, diagnostic workup including imaging and electrodiagnostic testing, conservative management, interventional treatments, and surgical indications. Excludes spinal cord compression (myelopathy), cauda equina syndrome (requires emergent surgical evaluation), thoracic radiculopathy, and post-surgical radiculopathy.

VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026

STATUS: Approved

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

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CLINICAL PEARLS: NERVE ROOT DISTRIBUTIONS

Cervical Radiculopathy (C5-T1)

Root	Motor Weakness	Reflex	Sensory Distribution
C5	Deltoid, biceps (shoulder abduction, elbow flexion)	Biceps	Lateral arm (deltoid region)
C6	Biceps, wrist extensors (elbow flexion, wrist extension)	Brachioradialis	Lateral forearm, thumb, index finger
C7	Triceps, wrist flexors, finger extensors (elbow extension)	Triceps	Middle finger
C8	Finger flexors, hand intrinsics (grip strength)	None reliable	Medial forearm, ring/small fingers
T1	Hand intrinsics (finger abduction/adduction)	None	Medial arm

Lumbar Radiculopathy (L2-S1)

Root	Motor Weakness	Reflex	Sensory Distribution
L2	Hip flexion (iliopsoas)	None	Anterior thigh (upper)
L3	Hip flexion, knee extension (quadriceps)	Patellar (reduced)	Anterior thigh (lower), medial knee
L4	Knee extension, ankle dorsiflexion (tibialis anterior)	Patellar	Medial leg, medial malleolus
L5	Ankle dorsiflexion, toe extension (EHL), hip abduction	None reliable	Lateral leg, dorsum of foot, great toe
S1	Ankle plantarflexion, toe flexion (gastrocnemius)	Achilles	Lateral foot, small toe, posterior calf

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RED FLAGS REQUIRING URGENT EVALUATION

Red Flag	Concern	Action
Bladder/bowel dysfunction (retention, incontinence)	Cauda equina syndrome	STAT MRI, emergent surgical consult
Saddle anesthesia	Cauda equina syndrome	STAT MRI, emergent surgical consult
Bilateral leg weakness	Cauda equina, myelopathy	STAT MRI, emergent surgical consult
Progressive motor deficit (<4/5 or rapidly worsening)	Severe nerve compression	Urgent MRI within 24h, surgical consult
Myelopathic signs (hyperreflexia, Babinski, gait ataxia)	Cervical myelopathy	Urgent MRI, cervical collar, surgical consult
Fever + back pain	Epidural abscess, discitis	STAT MRI with contrast, labs (WBC, ESR, CRP, blood cultures)
History of malignancy	Metastatic disease	STAT MRI with contrast, oncology consult
IV drug use + back pain	Epidural abscess	STAT MRI with contrast, infectious disease consult
Immunocompromised + back pain	Infection, atypical organisms	STAT MRI with contrast, expanded workup
Trauma + neurologic deficit	Unstable fracture, cord injury	STAT imaging (CT then MRI), spine surgery consult
Unexplained weight loss	Malignancy	MRI with contrast, cancer workup
Night pain unrelieved by rest	Tumor, infection	MRI with contrast

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SECTION A: ACTION ITEMS

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1. LABORATORY WORKUP

1A. Essential/Core Labs

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (85025)	STAT	STAT	ROUTINE	STAT	Infection screen if fever, malignancy screen	Normal WBC; no anemia
CMP - BMP + LFTs (80053)	STAT	STAT	ROUTINE	STAT	Baseline renal/hepatic function for medications; metabolic causes	Normal
ESR (85652)	URGENT	URGENT	ROUTINE	URGENT	Inflammatory marker for infection, malignancy, spondyloarthropathy	<20 mm/hr (age-adjusted)
CRP (86140)	URGENT	URGENT	ROUTINE	URGENT	Inflammatory marker for infection, malignancy	<0.5 mg/dL

1B. Extended Workup (Second-line)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
HbA1c (83036)	-	ROUTINE	ROUTINE	-	Diabetes increases neuropathy risk; affects surgical outcomes	<5.7%
Fasting glucose (82947)	-	ROUTINE	ROUTINE	-	Diabetes screening	<100 mg/dL
Vitamin B12 (82607)	-	ROUTINE	ROUTINE	-	Combined neuropathy may confuse presentation	>300 pg/mL
TSH (84443)	-	ROUTINE	ROUTINE	-	Hypothyroidism can cause myopathy, neuropathy	Normal (0.4-4.0 mIU/L)
HLA-B27 (86812)	-	EXT	ROUTINE	-	Ankylosing spondylitis, spondyloarthropathy if young patient with inflammatory back pain	Negative
Urinalysis (81001)	URGENT	ROUTINE	ROUTINE	-	UTI can mimic/exacerbate symptoms; pre-operative screen	Normal
PSA - males >50 (84153)	-	ROUTINE	ROUTINE	-	Prostate cancer metastases to spine	Age-appropriate normal
Blood cultures x2 (87040)	STAT	STAT	-	STAT	If fever or infection suspected	No growth

1C. Rare/Specialized (Refractory or Atypical)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
SPEP with immunofixation (86335, 86334)	-	EXT	EXT	-	Multiple myeloma with vertebral lesions	No M-spike
Lyme serology (86618)	-	EXT	EXT	-	Endemic areas with radiculopathy, polyradiculopathy	Negative
Paraneoplastic panel (86255)	-	EXT	EXT	-	Atypical presentation, weight loss, subacute course	Negative
ANA (86038)	-	EXT	EXT	-	Connective tissue disease	Negative or low titer
ACE level (82164)	-	EXT	EXT	-	Sarcoidosis with multifocal radiculopathy	Normal

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI spine without contrast - cervical (72141) or lumbar (72148)	STAT	URGENT	ROUTINE	STAT	STAT if red flags; otherwise after 4-6 weeks conservative treatment fails	Disc herniation, foraminal stenosis, nerve root compression	MRI-incompatible pacemaker; cochlear implant; metallic foreign body
MRI spine with and without contrast - cervical (72156) or lumbar (72158)	STAT	URGENT	ROUTINE	STAT	If infection, tumor, or inflammatory etiology suspected	Enhancement pattern (abscess rim, tumor, leptomeningeal)	GFR <30 (for gadolinium); MRI-incompatible device; gadolinium allergy
X-ray spine AP/lateral, flexion/extension - cervical (72050) or lumbar (72114)	URGENT	ROUTINE	ROUTINE	URGENT	Initial screen for instability, spondylolisthesis, fracture, alignment	No fracture, normal alignment, no listhesis	Pregnancy (shield abdomen)

2B. Extended

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT spine without contrast (72125/72131)	URGENT	URGENT	ROUTINE	URGENT	If MRI contraindicated; bony detail for fracture, foraminal stenosis	Foraminal narrowing, osteophytes, fracture	Pregnancy (relative); contrast allergy (if contrast used)
CT myelogram (72132)	-	EXT	EXT	-	MRI contraindicated and need for neural visualization	Filling defect at nerve root, cord compression	Coagulopathy (for LP); intracranial mass
EMG/NCS - electrodiagnostic studies (95886, 95909)	-	ROUTINE	ROUTINE	-	3-4 weeks after symptom onset to confirm radiculopathy, exclude peripheral neuropathy, localize level	Fibrillations/positive sharp waves in myotomal distribution; reduced recruitment	Pacemaker (relative for needle EMG); anticoagulation (relative)

2C. Rare/Specialized

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Diagnostic selective nerve root block (64483/64490)	-	EXT	ROUTINE	-	To confirm symptomatic level when imaging shows multilevel disease	>50% pain relief confirms level	Coagulopathy; infection at injection site; allergy to contrast/anesthetic
Bone scan - nuclear (78300)	-	EXT	ROUTINE	-	Suspected occult fracture, metastatic disease, infection	No increased uptake	Pregnancy
PET-CT (78816)	-	EXT	EXT	-	Occult malignancy, extent of metastatic disease	No FDG-avid lesions	Pregnancy; uncontrolled diabetes
Discography (62290)	-	-	EXT	-	Identify painful disc level before fusion (controversial)	Concordant pain reproduction	Coagulopathy; local infection; allergy

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Methylprednisolone	IV	Severe acute radiculopathy with significant weakness	125 mg :: IV :: once :: 125 mg IV once; may give for severe acute radicular symptoms	Active infection; uncontrolled diabetes; GI bleeding	Glucose; BP; GI symptoms	STAT	STAT	-	STAT
Dexamethasone	IV/PO	Acute severe radiculopathy, disc herniation with inflammation	10 mg :: IV :: once then 4 mg q6h :: 10 mg IV once, then 4 mg IV/PO q6h x 3-5 days; taper over 5-7 days	Active infection; uncontrolled diabetes; GI bleeding	Glucose; BP; psychiatric effects	STAT	STAT	ROUTINE	STAT
Prednisone	PO	Acute radiculopathy with moderate-severe symptoms	60 mg :: PO :: daily x 5 days :: 60 mg daily x 5 days then taper; OR Medrol dose pack	Active GI bleed; uncontrolled DM; active infection	Glucose; BP; mood	URGENT	URGENT	ROUTINE	-
Ketorolac	IV/IM	Acute pain, anti-inflammatory	30 mg :: IV :: q6h :: 30 mg IV/IM q6h; max 5 days; reduce to 15 mg if elderly/renal impairment	CrCl <30; active GI bleed; aspirin allergy; post-CABG	Renal function; GI bleeding	STAT	STAT	-	STAT
Morphine	IV	Severe acute radicular pain	2-4 mg :: IV :: q2-4h PRN :: 2-4 mg IV q2-4h PRN severe pain; titrate to effect	Respiratory depression; severe asthma; paralytic ileus	Respiratory status; sedation; pain scores	STAT	STAT	-	STAT
Hydromorphone	IV	Severe acute radicular pain (alternative to morphine)	0.5-1 mg :: IV :: q2-4h PRN :: 0.5-1 mg IV q2-4h PRN; titrate to effect	Respiratory depression; severe asthma; paralytic ileus	Respiratory status; sedation; pain scores	STAT	STAT	-	STAT
Diazepam	PO/IV	Acute muscle spasm	5 mg :: PO/IV :: q6-8h PRN :: 5-10 mg PO/IV q6-8h PRN for muscle spasm; short course (1-2 weeks)	Severe respiratory insufficiency; myasthenia gravis; acute narrow-angle glaucoma	Sedation; respiratory depression; dependence	URGENT	URGENT	-	-

3B. Symptomatic Treatments - Pain Management

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Ibuprofen	PO	Radicular pain, inflammation (first-line OTC)	400 mg :: PO :: TID :: 400-800 mg TID with food; max 3200 mg/day; short-term use preferred	CrCl <30; active GI bleed; aspirin allergy; third trimester pregnancy	GI symptoms; renal function with prolonged use	ROUTINE	ROUTINE	ROUTINE	-
Naproxen	PO	Radicular pain, inflammation (longer duration)	250 mg :: PO :: BID :: 250-500 mg BID with food; max 1500 mg/day	CrCl <30; active GI bleed; aspirin allergy; third trimester pregnancy	GI symptoms; renal function with prolonged use	ROUTINE	ROUTINE	ROUTINE	-
Meloxicam	PO	Radicular pain (once daily dosing)	7.5 mg :: PO :: daily :: 7.5-15 mg daily; max 15 mg/day	CrCl <30; active GI bleed; aspirin allergy	GI symptoms; renal function	-	ROUTINE	ROUTINE	-
Celecoxib	PO	Radicular pain (GI-sparing COX-2)	100 mg :: PO :: BID :: 100-200 mg BID; max 400 mg/day	Sulfonamide allergy; CAD/CVD (increased CV risk); CrCl <30	CV events; GI symptoms; renal function	-	ROUTINE	ROUTINE	-
Acetaminophen	PO	Mild-moderate pain (adjunct, avoid hepatotoxicity)	650 mg :: PO :: q6h :: 650-1000 mg q6h; max 3000 mg/day (2000 mg/day if liver disease)	Severe hepatic impairment; chronic alcohol use	LFTs with prolonged use	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Gabapentin	PO	Neuropathic/radicular pain (first-line for radiculopathy)	300 mg :: PO :: qHS :: Start 300 mg qHS; increase by 300 mg q1-3d; target 900-1800 mg TID; max 3600 mg/day	Renal impairment (adjust: CrCl 30-59 max 1400 mg/day; CrCl 15-29 max 600 mg/day; CrCl <15 max 300 mg/day)	Sedation; dizziness; edema; taper to discontinue	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Pregabalin	PO	Neuropathic/radicular pain (first-line alternative)	75 mg :: PO :: BID :: Start 75 mg BID; increase to 150 mg BID after 1 week; max 300 mg BID (600 mg/day)	Renal impairment (adjust per CrCl); Class V controlled	Sedation; weight gain; edema; dizziness	-	ROUTINE	ROUTINE	ROUTINE
Duloxetine	PO	Neuropathic/radicular pain with depression/anxiety	30 mg :: PO :: daily :: Start 30 mg daily x 1 week; increase to 60 mg daily; max 120 mg/day	Hepatic impairment; CrCl <30; MAOIs; narrow-angle glaucoma	Nausea; BP; discontinuation syndrome (taper over 2+ weeks)	-	ROUTINE	ROUTINE	-
Cyclobenzaprine	PO	Muscle spasm (short-term)	5 mg :: PO :: TID :: 5-10 mg TID; max 30 mg/day; limit to 2-3 weeks	Arrhythmia; heart failure; MAOIs within 14 days; hyperthyroidism	Sedation; anticholinergic effects; dry mouth	ROUTINE	ROUTINE	ROUTINE	-
Tizanidine	PO	Muscle spasm (alternative to cyclobenzaprine)	2 mg :: PO :: TID :: Start 2 mg TID; increase by 2-4 mg q6-8h; max 36 mg/day in divided doses	Concurrent ciprofloxacin or fluvoxamine (CYP1A2 inhibitors); hepatic impairment	LFTs at baseline, 1, 3, 6 months; sedation; hypotension	-	ROUTINE	ROUTINE	-
Methocarbamol	PO	Muscle spasm (less sedating)	1500 mg :: PO :: QID :: 1500 mg QID x 2-3 days, then 750 mg QID or 1500 mg TID	Renal impairment (use caution); myasthenia gravis	Sedation; dizziness (less than other relaxants)	ROUTINE	ROUTINE	ROUTINE	-
Baclofen	PO	Muscle spasm (if other relaxants fail)	5 mg :: PO :: TID :: Start 5 mg TID; increase by 5 mg/dose q3d; max 80 mg/day	Withdrawal risk if stopped abruptly; renal impairment	Sedation; weakness; must taper to discontinue (seizure risk)	-	ROUTINE	ROUTINE	-
Lidocaine patch 5%	TOP	Localized radicular pain	1-3 patches :: TOP :: 12h on/12h off :: Apply 1-3 patches to affected area for 12h on, 12h off	Severe hepatic impairment; broken skin	Minimal systemic absorption; local skin irritation	-	ROUTINE	ROUTINE	ROUTINE
Capsaicin cream 0.075%	TOP	Localized radicular pain (adjunct)	Apply thin layer :: TOP :: TID-QID :: Apply TID-QID to affected area; takes 2-4 weeks for effect	Open wounds; avoid eyes/mucous membranes	Initial burning (decreases with use); wash hands after	-	-	ROUTINE	-
Amitriptyline	PO	Neuropathic pain (second-line, helps sleep)	10 mg :: PO :: qHS :: Start 10-25 mg qHS; increase by 10-25 mg weekly; max 150 mg qHS	Cardiac conduction abnormality; recent MI; urinary retention; glaucoma; elderly	ECG if dose >100 mg/day; anticholinergic effects	-	ROUTINE	ROUTINE	-
Nortriptyline	PO	Neuropathic pain (second-line, less sedating than amitriptyline)	10 mg :: PO :: qHS :: Start 10-25 mg qHS; increase by 10-25 mg weekly; max 150 mg qHS	Cardiac conduction abnormality; recent MI; urinary retention; glaucoma; elderly	ECG if dose >100 mg/day; fewer anticholinergic effects than amitriptyline	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Tramadol	PO	Moderate radicular pain not controlled by NSAIDs/gabapentinoids	50 mg :: PO :: q6h PRN :: Start 50 mg q6h PRN; may use ER 100 mg daily; max 400 mg/day	Seizure disorder; MAOIs; SSRIs (serotonin syndrome); severe renal/hepatic impairment	Serotonin syndrome; seizures; dependence (Schedule IV)	-	ROUTINE	ROUTINE	-
Oxycodone	PO	Moderate-severe radicular pain (short-term)	5 mg :: PO :: q4-6h PRN :: 5-10 mg PO q4-6h PRN; for short-term use only	Respiratory depression; paralytic ileus; MAOIs	Sedation; constipation; respiratory status; dependence (Schedule II)	-	ROUTINE	ROUTINE	-
Oxycodone/Acetaminophen	PO	Moderate-severe radicular pain (short-term)	5/325 mg :: PO :: q4-6h PRN :: 5-10/325 mg q4-6h PRN; max acetaminophen 3000 mg/day	Respiratory depression; hepatic impairment; paralytic ileus	Sedation; respiratory status; LFTs; total acetaminophen intake	-	ROUTINE	ROUTINE	-
Epidural steroid injection (ESI)	Fluoroscopic	Radicular pain refractory to conservative treatment x 4-6 weeks	Per protocol :: Fluoroscopic :: q2-4 weeks x 3 :: Transforaminal or interlaminar approach; up to 3 injections per year	Coagulopathy (INR >1.5, plt <100k); infection at site; allergy to contrast/steroids	Post-procedure neuro exam; glucose (diabetics); headache	-	EXT	ROUTINE	-
Transforaminal ESI (TFESI)	Fluoroscopic	Unilateral radicular symptoms, foraminal stenosis	Per protocol :: Fluoroscopic :: q2-4 weeks x 3 :: More selective nerve root coverage than interlaminar; up to 3 per year	Coagulopathy; infection; severe foraminal stenosis	Post-procedure neuro check; glucose monitoring	-	EXT	ROUTINE	-
Medial branch blocks	Fluoroscopic	Facet-mediated pain component	Per protocol :: Fluoroscopic :: diagnostic x 2 :: Diagnostic blocks before radiofrequency ablation consideration	Coagulopathy; infection at site	Pain response documentation	-	-	ROUTINE	-
Radiofrequency ablation (RFA)	Fluoroscopic	Facet-mediated pain with positive diagnostic blocks	Per protocol :: Fluoroscopic :: once, repeat q6-12 mo :: If >50% relief from diagnostic medial branch blocks x 2	Coagulopathy; infection; pacemaker (relative)	Neurologic exam post-procedure; pain scores	-	-	ROUTINE	-

3D. Surgical Treatments (Specialist Decision)

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Microdiscectomy	Surgical	Herniated disc with refractory radiculopathy >6 weeks or progressive motor deficit	N/A :: Surgical :: once :: Standard of care for single-level disc herniation with radiculopathy	MRI confirmation; failed conservative therapy (unless emergent); medical clearance	Active infection; uncorrectable coagulopathy	Post-op neuro checks; wound monitoring; pain control	-	-	ROUTINE	-
Anterior cervical discectomy and fusion (ACDF)	Surgical	Cervical disc herniation with radiculopathy, cervical spondylosis with radiculopathy	N/A :: Surgical :: once :: Most common cervical spine procedure for radiculopathy	MRI confirmation; medical clearance; discussion of fusion alternatives	Active infection; severe osteoporosis (relative); uncorrectable coagulopathy	Swallowing assessment; airway monitoring; neuro checks	-	-	ROUTINE	-
Cervical disc arthroplasty	Surgical	Single-level cervical disc herniation (alternative to ACDF)	N/A :: Surgical :: once :: Motion-preserving alternative to fusion at appropriate levels (C3-7)	MRI confirmation; intact facet joints; no significant instability	Instability; facet arthropathy; osteoporosis; infection	Post-op neuro checks; wound monitoring	-	-	ROUTINE	-
Posterior cervical foraminotomy	Surgical	Lateral/foraminal cervical disc herniation or foraminal stenosis	N/A :: Surgical :: once :: Motion-preserving option for lateral pathology	MRI confirmation; lateral/foraminal pathology	Central disc herniation; instability	Post-op neuro checks; wound monitoring	-	-	ROUTINE	-
Lumbar laminectomy/laminotomy	Surgical	Lumbar stenosis with radiculopathy, large central disc	N/A :: Surgical :: once :: Decompression for stenosis or central disc	MRI confirmation; failed conservative therapy	Active infection; uncorrectable coagulopathy	Post-op neuro checks; wound; urinary retention	-	-	ROUTINE	-
Lumbar fusion (TLIF, PLIF, ALIF)	Surgical	Radiculopathy with instability, spondylolisthesis, recurrent disc herniation	N/A :: Surgical :: once :: Reserved for instability or recurrent pathology	MRI/CT confirmation; bone density evaluation; medical clearance	Active infection; severe osteoporosis (relative); uncorrectable coagulopathy	Post-op neuro checks; hardware position; fusion assessment	-	-	ROUTINE	-
Emergent decompression	Surgical	Cauda equina syndrome (within 48h), severe/progressive motor deficit	N/A :: Surgical :: emergent :: Within 24-48h of symptom onset for best outcomes	STAT MRI confirming compression	None absolute if true CES	Bladder function; motor recovery; wound	STAT	STAT	-	STAT

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Spine surgery (neurosurgery or orthopedic spine) consult STAT for cauda equina syndrome, progressive motor deficit, or myelopathic signs	STAT	STAT	-	STAT
Spine surgery consult URGENT for significant weakness (<4/5) or radiculopathy refractory to 6+ weeks conservative treatment	URGENT	URGENT	ROUTINE	URGENT
Physical therapy for core strengthening, McKenzie exercises, nerve gliding, and posture training	-	ROUTINE	ROUTINE	-
Pain management/Interventional spine for epidural steroid injections if conservative treatment fails after 4-6 weeks	-	ROUTINE	ROUTINE	-
PM&R (Physical Medicine & Rehabilitation) for comprehensive spine rehabilitation program	-	ROUTINE	ROUTINE	-
EMG/NCS referral to confirm radiculopathy level and exclude peripheral neuropathy or plexopathy (optimal timing 3-4 weeks after symptom onset)	-	ROUTINE	ROUTINE	-
Oncology consult for suspected spinal metastases or pathologic fracture	URGENT	URGENT	ROUTINE	URGENT
Infectious disease consult for suspected epidural abscess, discitis, or vertebral osteomyelitis	URGENT	URGENT	ROUTINE	URGENT
Rheumatology for suspected inflammatory spondyloarthropathy (ankylosing spondylitis, psoriatic arthritis)	-	ROUTINE	ROUTINE	-
Occupational therapy for ergonomic assessment, workplace modifications, and ADL training	-	ROUTINE	ROUTINE	-
Psychology/Pain psychology for chronic pain management, CBT for pain, catastrophizing assessment	-	-	ROUTINE	-
Neurology for atypical presentation, polyradiculopathy, or suspected inflammatory/infectious etiology	URGENT	URGENT	ROUTINE	URGENT
Social work for disability assistance, return-to-work planning, and insurance navigation	-	ROUTINE	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Return to ED IMMEDIATELY if bladder or bowel incontinence, inability to urinate, saddle area numbness, or bilateral leg weakness (may indicate cauda equina syndrome)	STAT	STAT	STAT
Return to ED if fever develops with back/neck pain (may indicate infection)	STAT	STAT	STAT
Return if weakness is progressing or you are unable to lift foot/hand (progressive motor deficit requires urgent evaluation)	STAT	STAT	STAT
Most radiculopathy improves with conservative treatment over 4-6 weeks; surgery is rarely needed	ROUTINE	ROUTINE	ROUTINE
Stay active within pain limits; prolonged bed rest (>1-2 days) is not recommended and may delay recovery	-	ROUTINE	ROUTINE
Apply ice for first 48-72 hours (20 min on/off), then switch to heat for muscle relaxation	ROUTINE	ROUTINE	ROUTINE
Avoid heavy lifting, twisting, and prolonged sitting; use proper body mechanics	ROUTINE	ROUTINE	ROUTINE
Sleep with pillow between knees (side) or under knees (back) to reduce spine stress	-	ROUTINE	ROUTINE
For cervical radiculopathy: avoid prolonged neck flexion (looking down at phone); use cervical pillow	-	ROUTINE	ROUTINE
Do not stop gabapentin/pregabalin abruptly - taper under medical guidance to avoid withdrawal	-	ROUTINE	ROUTINE
Neuropathic pain medications (gabapentin, pregabalin) take 2-4 weeks to reach full effect	-	ROUTINE	ROUTINE
Physical therapy exercises should be continued daily at home for best outcomes	-	ROUTINE	ROUTINE
Do not drive while taking opioids or sedating muscle relaxants	ROUTINE	ROUTINE	ROUTINE
Follow up with primary care or neurology in 2-4 weeks to assess treatment response	ROUTINE	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Smoking cessation to improve disc nutrition and surgical outcomes (smoking accelerates disc degeneration)	ROUTINE	ROUTINE	ROUTINE
Weight loss if BMI >25 to reduce spinal load and improve symptoms	-	ROUTINE	ROUTINE
Core strengthening exercises to support spine (plank, bird-dog, bridges)	-	ROUTINE	ROUTINE
Proper lifting technique: bend at knees, keep load close, avoid twisting	ROUTINE	ROUTINE	ROUTINE
Ergonomic workstation setup: monitor at eye level, lumbar support, feet flat	-	-	ROUTINE
Take breaks every 30-60 minutes if seated for prolonged periods	-	ROUTINE	ROUTINE
Maintain good posture: shoulders back, chin tucked, avoid forward head position	-	ROUTINE	ROUTINE
Regular low-impact exercise (walking, swimming, stationary bike) to maintain fitness	-	ROUTINE	ROUTINE
Avoid high-impact activities (running, jumping) during acute phase	-	ROUTINE	ROUTINE
Yoga or Pilates (modified) for flexibility and core strength after acute phase resolves	-	-	ROUTINE
Use supportive mattress; avoid sleeping on stomach	-	ROUTINE	ROUTINE
Manage stress as tension can worsen muscle spasm and pain perception	-	ROUTINE	ROUTINE
Glycemic control if diabetic (HbA1c <7%) to reduce neuropathic component and improve surgical outcomes	-	ROUTINE	ROUTINE

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SECTION B: REFERENCE

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5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Peripheral neuropathy	Stocking-glove distribution, bilateral, length-dependent, not dermatomal	NCS/EMG shows polyneuropathy; HbA1c; B12; no imaging abnormality
Lumbar spinal stenosis (neurogenic claudication)	Bilateral leg symptoms, worse with walking/standing, better with sitting/flexion, older patients	MRI shows central stenosis; symptoms bilateral; walking tolerance limited
Piriformis syndrome	Buttock pain radiating to posterior thigh, negative straight leg raise, tenderness at piriformis	MRI spine normal; tenderness at piriformis; FAIR test positive
Hip pathology (OA, AVN, labral tear)	Groin pain, limited hip ROM, pain with hip flexion/rotation, normal spine exam	Hip X-ray/MRI; pain reproduced with hip exam, not spine
Sacroiliac joint dysfunction	Low back/buttock pain, positive SI joint provocative tests, pain at PSIS	SI joint injection diagnostic; MRI may show SI joint changes
Greater trochanteric bursitis	Lateral hip pain, tender at greater trochanter, pain with side-lying	Normal spine MRI; tenderness localized to trochanter
Diabetic amyotrophy (lumbosacral plexopathy)	Acute/subacute proximal thigh weakness and pain, weight loss, often bilateral sequential	EMG shows plexopathy; MRI lumbosacral plexus may show enhancement
Meralgia paresthetica	Lateral thigh numbness/burning only (L2-L3 distribution), no weakness	Normal EMG; may have abnormal lateral femoral cutaneous nerve conduction
Herpes zoster (shingles)	Dermatomal pain followed by vesicular rash, older/immunocompromised	Clinical diagnosis; vesicular rash in dermatomal pattern
Vascular claudication	Calf pain with walking, relieved by rest (not position), diminished pulses	ABI <0.9; Doppler shows arterial disease; spine MRI normal
Cauda equina syndrome	Saddle anesthesia, bladder/bowel dysfunction, bilateral leg weakness/numbness	STAT MRI shows large central disc or mass compressing cauda equina
Spinal cord tumor (intra/extramedullary)	Progressive symptoms, night pain, myelopathic signs, weight loss	MRI with contrast shows enhancing mass
Epidural abscess	Fever, severe localized back pain, rapid progression, risk factors (IVDU, diabetes)	MRI with contrast shows rim-enhancing collection; elevated WBC, ESR, CRP
Vertebral metastases	History of cancer, night pain, weight loss, multiple levels	MRI shows destructive lesions; bone scan; tumor markers; biopsy
Ankylosing spondylitis	Young male, morning stiffness >30 min, improves with activity, sacroiliitis	HLA-B27; MRI shows sacroiliitis; ESR elevated
Spinal epidural hematoma	Post-procedure or anticoagulation, acute severe pain, rapid neuro decline	STAT MRI shows epidural collection; coags abnormal
Arachnoiditis	Prior spine surgery or infection, diffuse radicular symptoms, clumped nerve roots	MRI shows clumped/adherent nerve roots in thecal sac
Tarlov (perineural) cyst	Incidental finding on MRI, may cause radicular symptoms if large	MRI shows sacral cyst; often asymptomatic

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6. MONITORING PARAMETERS

Venue column indicates where monitoring is typically ordered/initiated. Most monitoring continues in outpatient setting.

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Pain scores (0-10 NRS)	Each visit	50% reduction from baseline	Escalate therapy; consider interventional/surgical referral	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Motor strength (MRC grading)	Each visit; more frequent if weakness present	Stable or improving; >=4/5	Progressive weakness: urgent spine surgery consult; imaging	STAT	STAT	ROUTINE	STAT
Sensory exam (dermatomal)	Each visit	Stable or improving	Document progression; correlate with imaging	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Deep tendon reflexes	Each visit	Symmetric or appropriate for level	Hyperreflexia suggests myelopathy: MRI cervical spine	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Bladder function	Each visit; more frequent if any symptoms	Normal voiding, no retention	Retention or incontinence: STAT catheterization, STAT MRI, emergent surgery consult	STAT	STAT	ROUTINE	STAT
Straight leg raise (lumbar) / Spurling test (cervical)	Each visit	Negative or improving	Positive with worsening: consider imaging if not done	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Gait assessment	Each visit	Normal, no foot drop, no ataxia	Foot drop: EMG, surgical consult; ataxia: cervical MRI for myelopathy	ROUTINE	ROUTINE	ROUTINE	ROUTINE
Functional status (ODI, NDI)	Baseline, 6 weeks, 3 months, 6 months	Improving scores	Not improving: reassess treatment strategy; consider surgery	-	ROUTINE	ROUTINE	-
Renal function (if on NSAIDs >2 weeks)	Baseline, then q3 months	Stable creatinine	Decline: discontinue NSAIDs; switch to acetaminophen/other	-	ROUTINE	ROUTINE	-
Glucose (if on steroids)	Daily if inpatient; before/after ESI	<180 mg/dL (diabetics)	Adjust diabetes medications; short steroid courses	ROUTINE	ROUTINE	ROUTINE	ROUTINE

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7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	No red flags present; pain controlled with oral medications; able to ambulate; normal bladder function; motor strength >=4/5 and stable; reliable follow-up arranged within 2-4 weeks
Admit to floor	Severe pain requiring IV analgesia; significant motor weakness (<=3/5) requiring close monitoring; need for IV antibiotics (suspected infection); inability to ambulate safely; need for urgent MRI not available as outpatient
Admit to ICU	Rapidly progressive motor deficit requiring emergent surgery; hemodynamic instability from sepsis (spinal infection); airway compromise (high cervical pathology); post-operative monitoring for complex spine surgery
Emergent surgery consult	Cauda equina syndrome (bladder dysfunction, saddle anesthesia, bilateral weakness); progressive motor deficit despite steroids; epidural abscess with neurologic deficit
Transfer to higher level	Spine surgery not available; MRI not available for emergent imaging; interventional spine services not available for ESI when indicated

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8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
MRI is imaging modality of choice for suspected radiculopathy	Class I, Level A	Boden SD et al. J Bone Joint Surg Am 1990
Most cervical and lumbar radiculopathy improves with conservative treatment	Class I, Level A	Saal JA et al. Spine 1996
NSAIDs effective for acute radiculopathy pain	Class I, Level A	Roelofs PD et al. Cochrane 2008
Gabapentin/pregabalin effective for radicular neuropathic pain	Class I, Level A	Finnerup NB et al. Lancet Neurol 2015
Oral steroids provide short-term benefit for lumbar radiculopathy	Class I, Level B	Goldberg H et al. JAMA 2015
Epidural steroid injections provide short-term pain relief for lumbar radiculopathy	Class I, Level B	Manchikanti L et al. Pain Physician 2021
EMG/NCS useful for confirming radiculopathy and excluding mimics after 3-4 weeks	Class II, Level B	AANEM Practice Parameter 2010
Surgery superior to conservative treatment for severe lumbar radiculopathy at 1 year	Class I, Level A	SPORT Trial: Weinstein JN et al. JAMA 2006
Cauda equina syndrome requires decompression within 48 hours for best outcomes	Class II, Level B	Ahn UM et al. Spine 2000
Physical therapy effective for cervical and lumbar radiculopathy	Class I, Level B	Kuijper B et al. BMJ 2009
Smoking cessation improves spine health and surgical outcomes	Class II, Level B	Battie MC et al. Spine 1991
Short-term muscle relaxants may help acute radiculopathy with spasm	Class II, Level B	Chou R et al. Cochrane 2003
ACDF effective for cervical radiculopathy refractory to conservative treatment	Class I, Level B	Herkowitz HN et al. Spine 1990
Microdiscectomy effective for lumbar disc herniation with radiculopathy	Class I, Level A	Peul WC et al. NEJM 2007
Duloxetine effective for chronic musculoskeletal pain including radiculopathy	Class I, Level A	Skljarevski V et al. J Pain 2010
Red flags warrant urgent imaging and evaluation for serious pathology	Class II, Level B	Chou R et al. Ann Intern Med 2007

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APPENDIX A: IMAGING DECISION ALGORITHM

When to Image

Immediate MRI (STAT): - Cauda equina syndrome symptoms - Progressive motor deficit (<4/5 or worsening) - Myelopathic signs (cervical) - Fever + back pain (add contrast for abscess) - History of malignancy + new back/neck pain - IV drug use + back pain

Urgent MRI (within 1-2 weeks): - Motor weakness (4/5) without progression - Intractable pain despite medications - Suspicion for tumor or infection without acute neuro deficit

Routine MRI (4-6 weeks): - Persistent radicular symptoms despite conservative treatment - To confirm level before intervention or surgery - Correlation with EMG findings

No MRI Needed: - Mild radicular symptoms <6 weeks responding to conservative treatment - No red flags present - Improving trajectory

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APPENDIX B: PHYSICAL THERAPY MODALITIES

Initial Phase (Week 1-2)

• Pain modulation: TENS, ice/heat, manual therapy
• Gentle ROM exercises
• Positioning education
• Nerve gliding/flossing exercises

Acute Phase (Week 2-4)

• McKenzie exercises (extension-based for disc, flexion-based for stenosis)
• Core stabilization (transverse abdominis activation)
• Postural training
• Progressive nerve mobilization

Strengthening Phase (Week 4-12)

• Progressive core strengthening (plank, bird-dog, bridges)
• Hip and leg strengthening
• Functional movement training
• Aerobic conditioning (walking, pool therapy)

Maintenance Phase (Ongoing)

• Independent home exercise program
• Return to activities with proper mechanics
• Work conditioning if applicable
• Ongoing core and flexibility maintenance

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CHANGE LOG

v1.1 (January 30, 2026) - Standardized lab tables (1A, 1B, 1C) to Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding format with CPT codes - Standardized imaging tables (2A, 2B, 2C) to Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications format with CPT codes - Fixed structured dosing first fields to starting_dose :: route :: frequency :: full_instructions format across all treatment sections - Standardized priority markers from checkmarks to STAT/ROUTINE in patient instructions and lifestyle tables - Fixed section header formatting to use ## SECTION format - Reorganized header block (DIAGNOSIS/ICD-10/SYNONYMS/SCOPE before VERSION) - Added REVISED date - Trimmed ICD-10 list to most clinically relevant codes - Bumped version to 1.1

v1.0 (January 27, 2026) - Initial creation - Comprehensive nerve root distribution tables for cervical (C5-T1) and lumbar (L2-S1) - Red flag checklist with required actions - Full laboratory workup including infection and malignancy markers - Imaging algorithm with timing recommendations - Treatment sections with structured dosing format for clickable order sentences - Multiple dose options for gabapentin, pregabalin, NSAIDs, muscle relaxants - Epidural steroid injection and interventional treatments - Surgical treatment section with indications and pre-treatment requirements - Comprehensive referral and patient instruction sections - Differential diagnosis including 18+ alternative diagnoses - Evidence-based references with PubMed links - Appendices for imaging decision algorithm and PT modalities

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