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Parham Rasoulinejad, MD, FRCSC, MSc, 1 Jennifer C. Urquhart, PhD,2 Christopher S. Bailey, MD, FRCSC, MSc, 2

1Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Assistant Professor, Dept. of Surgery, University of Western Ontario, London, ON.
2Research Associate, Division of Orthopaedic Surgery, London Health Sciences Center, and Lawson Health Research Institute, London, ON.
3Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Associate Professor, Dept. of Surgery, University of Western Ontario, London, ON.

CLINICAL TOOLS

Abstract: Lumbar disc herniation is a common cause of low back pain and radiculopathy (sciatica). Diagnosis is initially made based on history and physical examination and ruling out red flags, particularly surgical emergencies such as Cauda Equina Syndrome. A trial of conservative treatment consisting of physical rehabilitation and oral medication is usually successful for back dominant pain. When persistent radiculopathy indicates lumbar discectomy the diagnosis must be confirmed by imaging but, due to very high rates of asymptomatic disc herniation, imaging cannot replace clinical diagnosis. For disabling leg dominant pain discectomy results in faster recovery but has a similar long-term outcomes compared to conservative treatment.
Key Words: lumbar disc herniation, lower back pain, sciatica, radiculopathy.

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Lumbar disc herniation is common and frequently asymptomatic.
Lumbar disc herniation may result in back pain. Much less frequently, when the adjacent nerve root is involved it can cause radiculopathy (sciatica).
Under most circumstances, the symptoms of lumbar disc herniation can be managed conservatively with physical rehabilitation and oral medications.
Red flags and surgical emergencies such as Cauda Equina Syndrome must be considered and should lead to urgent imaging and surgical referral.
Imaging, particularly MRI, has high rates of false positives and should only be used to confirm a diagnosis made based on history and physical examination.
For disabling persistent radiculopathy with good radiological correlation, surgical intervention in the form of a discectomy can be considered.
Lumbar disc herniation (LDH) is common and in most cases asymptomatic. Findings on MRI of lumbar disc herniation are not predictive of future back related disability. MRI findings should be interpreted along with history and physical exam findings to determine the appropriate diagnosis.
LDH can result in back pain and, when the adjacent nerve root is involved, radicular leg pain. The first line of treatment for back dominant pain should be education, lifestyle modification, mechanical therapy and oral medications in the form of acetaminophen, non-steroidal anti-inflammatories.
Radicular leg dominant pain may require opioids and/or epidural corticosteroid injections. The majority of patients will improve without further intervention.
For persistent symptoms of sciatica, surgical intervention can be considered. Lumbar discectomy is the most common procedure performed and has good to excellent outcomes.
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