Evidence-Based Conservative Treatment Strategies for Lumbar Radiculopathy: A Systematic Review

Lumbar radiculopathy is a prevalent and debilitating spinal condition that causes severe pain, functional impairment, and diminished quality of life. Although conservative treatments are widely recommended as first-line management, establishing their comparative effectiveness remains challenging due to substantial heterogeneity in the literature. This systematic review synthesized and critically appraised the evidence evaluating non-surgical, conservative interventions for lumbar radiculopathy. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, this review was prospectively registered with PROSPERO (CRD420261407070). Comprehensive electronic searches were conducted across PubMed, Scopus, Web of Science, Embase, and the Cochrane Library up to 2026. Randomized controlled trials (RCTs) involving participants with clinically or radiologically confirmed lumbar radiculopathy were eligible for inclusion. Methodological quality was evaluated using the Cochrane Risk of Bias 2 (RoB 2) tool. Due to marked clinical and methodological heterogeneity, a quantitative meta-analysis was precluded, and a structured narrative synthesis was performed instead. Nineteen RCTs published between 2016 and 2026 met the inclusion criteria. The investigated therapies included manual therapy, neural mobilization, exercise rehabilitation, physical modalities, and multimodal regimens. Rather than purely qualitative benefits, individual trials demonstrated quantifiable short-term improvements. Manual therapy combined with exercise or neurodynamics yielded significant advantages over conventional care; for instance, adding spinal mobilization with leg movement (SMWLM) achieved a mean difference (MD) in leg pain reduction of 2.0 (95% CI: 1.4 to 2.6) at two weeks and 2.6 (95% CI: 1.9 to 3.2) at six months. Similarly, targeted neural mobilization outperformed traditional therapy at eight weeks (pain MD: -2.4, 95% CI: -3.1 to -1.7; disability MD: -12.8%, 95% CI: -16.1% to -9.5%). Traditional Persian manual therapy combined with exercise reduced low back pain by 4.28 units (95% CI: 3.36 to 5.19). However, clinical superiority was inconsistent across all outcome domains, long-term follow-ups were rare, and conservative treatment non-response or failure remained a distinct clinical possibility. Methodological limitations, including a high risk of bias regarding incomplete blinding of participants/therapists and selective outcome reporting, were frequently observed across multiple trials. Conservative interventions yield measurable, statistically significant short-term improvements in pain and function for lumbar radiculopathy. However, the overall certainty of the evidence is limited by high clinical heterogeneity and trial-level methodological constraints, which precluded data pooling. Findings should be interpreted cautiously, and further high-quality trials with standardized outcomes and adverse event reporting are required.