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The patient presents with signs and symptoms of left-sided L4 radiculopathy. In order for the disc to involve the dorsal root ganglia and cause L4 radiculopathy, he would need to have a far lateral disc herniation at the L4-5 level, as shown by circle D. Lumbar disc herniations most commonly occur at the L4-5 and L5-S1 levels. Surgical interventions are indicated when symptoms last more than 6 weeks and the patient has failed nonoperative measures. The signs and symptoms of these herniations depend on the level and sagittal location of pathology. Paracentral disc herniations, the most common type, typically affect the traversing root at a disc level (i.e. the L4 nerve root at the L3-4 level). Foraminal and far lateral disc herniations affect the exiting root at the corresponding disc level (i.e. the L3 nerve root at the L3-4 level). In very rare cases, a larger, broad disc herniation can affect both the traversing and exiting nerve root. Weinstein et al. reviewed the outcomes of surgical and conservative treatments for lumbar disc herniations. They reported improved pain and function in the surgical group at 3 months, with results narrowing slightly at 2 years. They concluded that these results may be subject to potential confounding due to a non-randomized cohort in this specific study. Yorimitsu et al. reviewed the 10-year outcomes on patients who underwent surgery for lumbar disc herniation. They reported nearly a 75% rate of residual back pain, and those patients with a loss of disc height were more likely to have lower outcome scores. They concluded that patients with retained disc height were at higher risk of re-herniation. Figure A shows a series of sagittal and axial T2 MRI sequences showing possible locations of various disc herniations. Their clinical implications are discussed below. Incorrect Answers: Answer 1: Circle A would be a paracentral L3-4 disc herniation contacting the traversing L4 nerve root. However, there would be no involvement of the dorsal root ganglia. Answer 2: Circle B would be a far lateral L3-4 disc herniation contacting the exiting L3 nerve root. Answer 3: Circle C would be a paracentral L4-5 disc herniation contacting the traversing L5 nerve root. Answer 5: Circle E would be a far lateral L5-S1 disc herniation contacting the exiting L5 nerve root.
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