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For further information, see CMDT Part 41-03: Spine Problems

Key Features

  • Usually due to bending or heavy loading (eg, lifting) with the back in flexion

  • However, there may not be an inciting incident

  • Usually occur from degenerative disk disease (dessication of the annulus fibrosis) in patients between 30- and 50-years-old

  • Discogenic pain typically is localized in the low back at the level of the affected disk and is worse with activity

  • The L5–S1 disk is affected in 90% of cases

Clinical Findings

  • Pain with back flexion or prolonged sitting

  • Numbness and weakness

  • Radicular pain into the leg due to compression of neural structures

  • Severe compression of the spinal cord can cause the cauda equina syndrome, a surgical emergency

    • The cauda equina syndrome should be ruled out if the patient complains of perianal numbness or bowel or bladder incontinence

Diagnosis

  • Plain radiographs are helpful to assess

    • Spinal alignment (scoliosis, lordosis)

    • Disk space narrowing

    • Osteoarthritis changes

  • MRI is the best method to assess the level and morphology of the herniation and is recommended if surgery is planned

Treatment

  • For an acute exacerbation of pain symptoms, bed rest is appropriate for up to 48 hours

  • Otherwise, first-line treatments include

    • Modified activities

    • NSAIDs and other analgesics

    • Physical therapy, including core stabilization and McKenzie exercises

  • Epidural and transforaminal corticosteroid injections

    • Can be beneficial, especially in relieving acute radicular pain, although the benefit tends to last only 3 months

    • These epidural injections have not shown any change in long-term surgery rates

  • Oral prednisone

    • Can reduce inflammation and is useful in reducing symptoms of acute sciatica

    • Initial dose: approximately 1 mg/kg once daily with tapering doses over 10–15 days

  • Co-analgesics for neuropathic pain (eg, gabapentin, pregabalin, or tricyclic antidepressants) may be helpful

  • Microdiscectomy is the standard method of treatment with a low rate of complications and satisfactory results over 90% in the largest series

  • Percutaneous endoscopic discectomy

    • Minimally invasive technique that involves using an endoscope to remove fragments of disk herniation (interlaminar or transforaminal approaches) under local anesthesia

    • However, results are less successful than microdiscectomy

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