Background: Lumbar radiculopathies are common and cause significant pain and functional limitations. The optimal strategy between conservative physiotherapeutic and surgical approaches remains debated. Objective: Evidence-based comparison of conservative and surgical strategies regarding pain reduction and functional improvement within a biopsychosocial framework. Methods: Structured narrative review with systematic searches in PubMed/MEDLINE, Cochrane Library, and PEDro using a PICO-based strategy, focusing on studies published between 2020 and 2025, with two key references from 2018 additionally retained from a 10 year database sweep because of their contextual relevance; predefined eligibility criteria (peer reviewed human studies in English or German); thematic synthesis. Single reviewer screening without duplicate screening or formal risk of bias assessment; no protocol registered; no systematic search of grey literature or trial registries; last search November 5, 2025. Results: Physiotherapeutic approaches, including exercise with targeted multifidus activation and cognition-oriented motor control, show relevant improvements. Epidural injections and, if needed, gabapentin may provide short-term relief. Surgical procedures, particularly microdecompression or microdiscectomy, yield faster early gains but converge with conservative outcomes in the medium and long term. Reoperation rates and functional outcomes show no consistent superiority. Psychosocial factors such as distress and catastrophizing affect recovery and should be screened. Conclusion: In the absence of red flags or severe deficits, conservative therapy addressing psychosocial factors should be prioritized within shared decision-making. Surgery is reserved for significant symptom burden, progressive deficits, or failed conservative care.