Review Question - QID 214053

The patient is presenting with an L5-S1 right large paracentral disc herniation with S1 radiculopathy and progressive neurologic deficit despite conservative treatment. Of the given answer choices, a right L5-S1 microdiscectomy would be the most appropriate treatment option.

Lumbar disc herniation most commonly occurs at the L4-L5 and L5-S1 level and peaks in incidence in patients 30-50 years of age. Approximately 90% of symptomatic lumbar disc herniations improve with nonoperative treatment modalities consisting of physical therapy, muscle relaxants, oral steroids, steroid injections, and activity modifications. However, patients that have persistent pain and disability lasting more than 6 weeks, progressive weakness, or findings of cauda equina syndrome should undergo a microdiscectomy.

Nezari et al. performed a systematic review and meta-analysis of the diagnostic accuracy of neurologic examinations for lumbar disc herniation with suspected radiculopathy. The authors included 14 studies of which they reported sensory, motor, and reflex sensitivities of 0.32, 0.4, and 0.25, respectively for radiographically confirmed disc herniations. The authors concluded that neurologic testing has limited diagnostic accuracy for detecting lumbar disc herniation.

Amin et al. reviewed the recent advances in lumbar disc herniation. They reported on several recently proposed etiologies for lumbar disc herniation, including aquaporin polymorphisms, axial overloading from prolonged sitting, inflammatory cytokines, Propionibacterium acnes, and acidic environment. They concluded that minimally invasive techniques, such as endoscopic microdiscectomy, demonstrate increasingly positive outcomes.

Figures A and B are the lateral flexion and extension radiographs of the lumbar spine without evidence of instability or spondylolisthesis. Figures C and D are the sagittal and axial T2-weighted MRI images of the lumbar spine with a large right paracentral herniated disc at L5-S1 with the encroachment of the S1 nerve root.

Incorrect Answers:
Answer 1: A repeat MRI of the lumbar spine would likely not add any further diagnostic information since the previous study demonstrated a large herniation that corroborates with the patient's clinical findings.
Answer 2: An L5-S1 laminectomy alone would not address the herniated disc and would likely result in persistent radiculopathy and weakness.
Answer 3: Bed rest would not be a preferred treatment option in the presence of progressive motor weakness and the associated deconditioning that occurs.
Answer 5: An L5-S1 anterior lumbar interbody fusion can be performed for discogenic back pain, facetogenic back pain, radiculopathy from degenerative foraminal stenosis, and instability. In the context of radiculopathy from a lumbar herniated disc, a microdiscectomy would be a better surgical option that would preserve motion at the L5-S1 segment.