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

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

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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.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

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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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Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.
Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto's Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article highlights the myths and misunderstandings surrounding the straight leg raise (SLR) test for sciatica. Unfortunately, neither intra- nor inter-observer reliability of the passive SLR test has ever been agreed upon. In addition, there is poor consensus about what constitutes a positive SLR test in terms of pain location, leg elevation limitation or clinical significance. Until there are stricter performance standards and uniform agreement, researchers and clinicians should interpret the test with caution. We believe a true positive SLR should be the reproduction or exacerbation of the typical leg dominant pain in the affected limb at any degree of passive elevation. Those with only increased back pain or any leg pain other than that presenting as the chief complaint should be regarded as false positives.
Key Words: low back pain, straight leg raise, sciatica, irritative test.