Guidelines Summary

The following guidelines were published by the North American Spine Society^[33]:

Manual muscle testing, sensory testing, supine straight leg raise, Lasegue's sign, and crossed Lasegue's sign are recommended for use in diagnosing lumbar disc herniation with radiculopathy. The supine straight leg raise, as compared with the seated straight leg raise, is suggested for use in diagnosing lumbar disc herniation with radiculopathy.

In patients with a history and physical examination findings consistent with lumbar disc herniation with radiculopathy, MRI is considered as the most appropriate, noninvasive test to confirm the presence of lumbar disc herniation. If MRI is econtraindicated or inconclusive, CT or CT myelography is the next most appropriate test..

Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve accuracy of medication delivery.

Transforaminal epidural steroid injection is recommended to provide short-term (2–4 wk) help provide pain relief in patients with lumbar disc herniations with radiculopathy.

Endoscopic percutaneous discectomy is suggested for carefully selected patients to reduce early postoperative disability and reduce opioid use, as compared with open discectomy in the treatment of patients with lumbar disc herniation with radiculopathy.

If surgery is indicated, sequestrectomy or aggressive discectomy is recommended for decompression in patients with lumbar disc herniation with radiculopathy because there is no difference in rates of reherniation.

Questions

Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014 Nov 1. 14 (11):2525-45. [QxMD MEDLINE Link].
Donnally III CJ, Dulebohn SC. Lumbar Degenerative Disk Disease. 2017 Jun. [QxMD MEDLINE Link]. [Full Text].
Donnally III CJ, Dulebohn SC. Lumbosacral Disc Injuries. 2017 Jun. [QxMD MEDLINE Link]. [Full Text].
Truumees E. A history of lumbar disc herniation from Hippocrates to the 1990s. Clin Orthop Relat Res. 2015 Jun. 473 (6):1885-95. [QxMD MEDLINE Link].
Steinberger J, Skovrlj B, Caridi JM, Cho SK. The top 100 classic papers in lumbar spine surgery. Spine (Phila Pa 1976). 2015 May 15. 40 (10):740-7. [QxMD MEDLINE Link].
Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med. 2017 Dec. 10 (4):507-516. [QxMD MEDLINE Link].
Korse NS, Pijpers JA, van Zwet E, Elzevier HW, Vleggeert-Lankamp CLA. Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction. Eur Spine J. 2017 Mar. 26 (3):894-904. [QxMD MEDLINE Link].
Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976). 2008 Oct 15. 33 (22):2464-72. [QxMD MEDLINE Link].
Splendiani A, Perri M, Grattacaso G, Di Tunno V, Marsecano C, Panebianco L, et al. Magnetic resonance imaging (MRI) of the lumbar spine with dedicated G-scan machine in the upright position: a retrospective study and our experience in 10 years with 4305 patients. Radiol Med. 2016 Jan. 121 (1):38-44. [QxMD MEDLINE Link].
Chung TS, Yang HE, Ahn SJ, Park JH. Herniated Lumbar Disks: Real-time MR Imaging Evaluation during Continuous Traction. Radiology. 2015 Jun. 275 (3):755-62. [QxMD MEDLINE Link].
Majeed SA, Seshadrinath NA, Binoy KR, Raji L. Lumbar disc herniation: Is there an association between histological and magnetic resonance imaging findings?. Indian J Orthop. 2016 May-Jun. 50 (3):234-42. [QxMD MEDLINE Link].
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006 Nov 22. 296(20):2441-50. [QxMD MEDLINE Link].
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006 Nov 22. 296(20):2451-9. [QxMD MEDLINE Link].
Mazanec D, Okereke L. Interpreting the Spine Patient Outcomes Research Trial. Medical vs surgical treatment of lumbar disk herniation: implications for future trials. Cleve Clin J Med. 2007 Aug. 74(8):577-83. [QxMD MEDLINE Link].
Thiru M. Annaswamy, MD and Charles Taylor, II MD, PhD. Lumbar Disc disorders. American Academy of Physical Medicine and Rehabilitation. Available at https://now.aapmr.org/lumbar-disc-disorders/. 08/18/2017; Accessed: September 25, 2018.
Jo Jordan, Tamara Shawver Morgan, James Weinstein, Kika Konstantinou. Herniated Lumbar Disk. American Academy of Family Physicians. Available at https://www.aafp.org/afp/2006/0401/p1240.html. Accessed: September 25, 2018.
Suthar P, Patel R, Mehta C, Patel N. MRI evaluation of lumbar disc degenerative disease. J Clin Diagn Res. 2015 Apr. 9 (4):TC04-9. [QxMD MEDLINE Link].
Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19. 313 (19):1915-23. [QxMD MEDLINE Link].
Nakagawa H, Kamimura M, Takahara K, et al. Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation. J Clin Neurosci. 2007 Feb. 14(2):104-9. [QxMD MEDLINE Link].
Iversen T, Solberg TK, Romner B, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011 Sep 13. 343:d5278. [QxMD MEDLINE Link].
Mirzai H, Tekin I, Yaman O, et al. The results of nucleoplasty in patients with lumbar herniated disc: a prospective clinical study of 52 consecutive patients. Spine J. 2007 Jan-Feb. 7(1):88-92; discussion 92-3. [QxMD MEDLINE Link].
Soliman J, Harvey A, Howes G, Seibly J, Dossey J, Nardone E. Limited microdiscectomy for lumbar disk herniation: a retrospective long-term outcome analysis. J Spinal Disord Tech. 2014 Feb. 27 (1):E8-E13. [QxMD MEDLINE Link].
Mahesha K. Percutaneous endoscopic lumbar discectomy: Results of first 100 cases. Indian J Orthop. 2017 Jan-Feb. 51 (1):36-42. [QxMD MEDLINE Link].
Wilson CA, Roffey DM, Chow D, Alkherayf F, Wai EK. A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy. Spine J. 2016 Nov. 16 (11):1413-1422. [QxMD MEDLINE Link].
Schmid SL, Wechsler C, Farshad M, Antoniadis A, Ulrich NH, Min K, et al. Surgery for lumbar disc herniation: Analysis of 500 consecutive patients treated in an interdisciplinary spine centre. J Clin Neurosci. 2016 May. 27:40-3. [QxMD MEDLINE Link].
Celik SE, Celik S, Kara A, et al. Lumbar facet joint angle and its importance on joint violation in lumbar microdiscectomy. Neurosurgery. 2008 Jan. 62(1):168-72; discussion 172-3. [QxMD MEDLINE Link].
Eugene J. Carragee, MD, Anthony O. et al. A Prospective Controlled Study of Limited VersusSubtotal Posterior Discectomy: Short-Term Outcomesin Patients With Herniated Lumbar Intervertebral Discsand Large Posterior Anular Defect. Spine. 2006. 31:653-657.
Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of Symptoms Resulting from Lumbar Disc Herniation: Effect on Treatment Outcomes: Analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am. 2011 Oct 19. 93(20):1906-14. [QxMD MEDLINE Link].
Sørensen IG, Jacobsen P, Gyntelberg F, Suadicani P. Occupational and Other Predictors of Herniated Lumbar Disc Disease-A 33-Year Follow-up in The Copenhagen Male Study. Spine (Phila Pa 1976). 2011 Sep 1. 36(19):1541-6. [QxMD MEDLINE Link].
Dohrmann GJ, Mansour N. Long-Term Results of Various Operations for Lumbar Disc Herniation: Analysis of over 39,000 Patients. Med Princ Pract. 2015. 24 (3):285-90. [QxMD MEDLINE Link].
Hoogland T, van den Brekel-Dijkstra K, Schubert M, et al. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine. 2008 Apr 20. 33(9):973-8. [QxMD MEDLINE Link].
Arts M, Brand R, van der Kallen B, Lycklama à Nijeholt G, Peul W. Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial. Eur Spine J. 2011 Jan. 20(1):51-7. [QxMD MEDLINE Link].
North American Spine Society. Recommendations for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. Guideline Central. Available at https://www.guidelinecentral.com/summaries/clinical-guidelines-for-diagnosis-and-treatment-of-lumbar-disc-herniation-with-radiculopathy/#section-society. 2012; Accessed: September 25, 2018.
Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther. 2008 Jan. 31(1):33-88. [QxMD MEDLINE Link].
Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome. J Neurosurg Spine. 2005 Jun. 2(6):639-46. [QxMD MEDLINE Link].
Ehni BL, Benzel EC. Lumbar Discectomy. Spine Surgery. 1999. 1:389-400.
Hardy RW. Extradural Cauda Equina and Nerve Root Compression from Benign Lesions of the Lumbar Spine. Neurological Surgery. 1996. 3:2357-2374.
Loupasis GA, Stamos K, Katonis PG, et al. Seven- to 20-year outcome of lumbar discectomy. Spine. 1999 Nov 15. 24(22):2313-7. [QxMD MEDLINE Link].
Williams RW. Lumbar disc disease. Microdiscectomy. Neurosurg Clin N Am. 1993 Jan. 4(1):101-8. [QxMD MEDLINE Link].
Woertgen C, Rothoerl RD, Breme K, et al. Variability of outcome after lumbar disc surgery. Spine. 1999 Apr 15. 24(8):807-11. [QxMD MEDLINE Link].

Media Gallery

Degenerative lumbar disc disease. The various forces placed upon the discs of the lumbar spine that can result in degenerative changes.
Degenerated lumbar disc disease.
Magnetic resonance image of a herniated nucleus pulposus of the lumbar spine.

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Author

Kamran Sahrakar, MD, FACS Clinical Professor, Department of Neurosurgery, University of California, San Francisco, School of Medicine

Kamran Sahrakar, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, Congress of Neurological Surgeons, American Association of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Parkinson and Movement Disorder Society, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting; Received Consulting Fee from ClearPoint Neuro.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Martin Melicharek, MD Assistant Clinical Professor, Department of Neurosurgery, University of California at Davis

Martin Melicharek, MD is a member of the following medical societies: American Association of Neurological Surgeons, California Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

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