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Parham Rasoulinejad, MD, FRCSC, MSc, Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Assistant Professor, Dept. of Surgery, University of Western Ontario, London, ON.
Jennifer C. Urquhart, PhD, Research Associate, Division of Orthopaedic Surgery, London Health Sciences Center, and Lawson Health Research Institute, London, ON.
Christopher S. Bailey, MD, FRCSC, MSc, Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Associate Professor, Dept. of Surgery, University of Western Ontario, London, ON.
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.
Introduction
Degenerative spine conditions and lumbar disc herniation (LDH) have afflicted humanity since ancient time. Hippocrates described sciatica and antalgic posture as well as claudication and prescribed rest, massage, heat, dietary changes and music.1 Although LDH was thought to be due to traumatic causes, studies have demonstrated a strong genetic susceptibility to both disc herniation and degeneration.2,3 Back pain occurs spontaneously in over 60% of cases.4
The incidence of symptomatic LDH in the United States is 2% to 5% and the lifetime prevalence is nearly 80%.5-7 LDH occurs most commonly between the ages of 40 and 45 with the majority of the LDH occurring at the L4/L5 and L5/S1 levels.8 When pain is present LDH usually results in two types of symptoms: 1) most commonly localized back dominant pain termed as mechanical back pain and 2) in a small number of case sciatica or radiculopathy when the herniation irritates one or more adjacent nerve roots. Symptoms of mechanical back pain and radicular leg pain can coexist.