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Patrick Thornley, MD, MSc, FRCSC,1, Christopher S. Bailey, MD, MSc, FRCSC,2,

1 London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, Ontario, Canada.
2 London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, Ontario, Canada.

CLINICAL TOOLS

Abstract: Lumbar intervertebral disc herniations (IVH) carry a high lifetime prevalence and are the most common cause of sciatica. The vast majority of symptomatic lumbar IVH improve with conservative management though adjuncts such as physiotherapy and epidural steroid injections may play a role in short-term symptom relief. For patients with unresponsive lumbar IVH, discectomy reliably improves symptoms more rapidly than continued conservative care, though there is inconsistent evidence that clinical differences between operative and conservative care are no different at one-year after symptom onset.
Key Words: lumbar radiculopathy, intervertebral disc herniation; lumbar intervertebral disc herniation; lumbar disc herniation; sciatica.

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1. The natural history of lumbar intervertebral disc herniations causing lumbar radiculopathy is favourable with conservative care in the vast majority of patients.
2. Advanced imaging for patients with lumbar radiculopathy is indicated only in the setting of “red flag” neurologic symptoms or a concerning clinical history for infection, neoplastic or traumatic etiology or the absence of symptom improvement after six-weeks of conservative care.
3. Long-term follow-up demonstrates most patients with lumbar intervertebral disc herniation causing lumbar radiculopathy achieve comparable clinical improvement with surgery or conservative management, with surgery leading to earlier symptom resolution.
4. The high-quality evidence for surgery is weak given the high cross over rate but observational studies show a benefit of surgery after failed non-operative care.
1. The diagnosis is made on the patient’s history including leg dominant pain and confirmed by the physical examination.
2. A combination of a detailed motor and sensory neurologic examination, including supine straight leg raise in addition to cross leg straight leg raise, increases the clinical sensitivity and specificity of a diagnostic examination for lumbar radiculopathy.
3. Analgesics should be used to manage function and not just to reduce pain, taking into account response to the specific analgesic on an individual basis including the known side effect profiles.
4. Microdiscectomy surgery for patients with refractory lumbar radiculopathy lasting greater than four months can lead to a significant reduction in leg pain compared to continued conservative management.
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Related Terms: Back Health, lumbar radiculopathy, intervertebral disc herniation, lumbar intervertebral disc herniation, Lumbar disc herniation, sciatica