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

Key Features

Essentials of Diagnosis

  • Pain with back flexion or prolonged sitting

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

  • Lower extremity numbness and weakness

General Considerations

  • Usually due to bending or heavy loading (eg, lifting) with the back in flexion, causing herniation or extrusion of disk contents (nucleus pulposus) into the spinal cord area

  • However, there may not be an inciting incident

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

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

  • Compression of neural structures, such as the sciatic nerve, causes radicular pain

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

Clinical Findings

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

  • "Sciatica" causes electric shock-like pain radiating down the posterior aspect of the leg often to below the knee

  • Symptoms usually worsen with back flexion such as bending or sitting for long periods (eg, driving)

  • A significant disk herniation can cause numbness and weakness, including weakness of plantar flexion of the foot (L5/S1) or dorsiflexion of the toes (L4/L5)

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


  • Plain radiographs are helpful to assess

    • Spinal alignment (scoliosis, lordosis)

    • Disk space narrowing

    • Osteoarthritic changes

  • MRI

    • Best method to assess the level and morphology of the herniation

    • Recommended if surgery is planned


Conservative measures


  • Oral prednisone

    • Caused a modest improvement in function at 3 weeks but there was no significant improvement in pain in patients with acute radiculopathy who were monitored for 1 year in a randomized trial

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

  • Analgesics for neuropathic pain may be helpful, such as

    • Calcium channel alpha-2-delta ligands (ie, gabapentin, pregabalin)

    • Tricyclic antidepressants


  • The severity of pain and disability as well as failure of conservative therapy are the most important reasons for surgery

  • Microdiskectomy

    • Standard method of treatment

    • Low rate of complications

    • Satisfactory results in over 90% in the largest series

  • Minimally invasive percutaneous endoscopic spine surgery

    • Uses an endoscope to remove fragments of disk herniation (interlaminar or transforaminal approaches) under ...

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