Review Question - QID 4590

The clinical presentation is consistent for a lumbar disc herniation with symptoms of S1 radiculopathy that has failed to improve with extensive nonoperative treatment. At this time a discectomy would lead to the greatest improvement in physical functioning.

Lumbar disc herniations are the result of recurrent torsional strain that leads to tears of outer annulus, and ultimately herniation of the nucleus pulpous. The vast majority of patients (90%) will have improvement of their symptoms following 3 months of nonoperative treatment. Over time, the disc herniation slowly decreases in size and resorbs, leading to an improvement of symptoms. Operative intervention, however, may be considered in patients who continue to have debilitating pain or have only minimal improvement in symptoms following at least 6 weeks of nonoperative treatment including physical therapy and epidural steroid injections. For these patients, if no instability is identified, discectomy is the treatment of choice. In this subset of patients, surgical intervention results in greater improvements in pain and functional recovery compared to continued nonoperative treatment.

Anderson et al. reviewed the adequacy of randomized controlled studies completed over 25 years (1983-2007) that attempted to compare discectomy with non-surgical treatment. Given the high crossover rates and heterogeneity of outcome measures, the authors are unable to make conclusions as to the benefit of one treatment modality over another.

Weinstein et al. reviewed greater than 1000 patients who had imaging confirmed lumbar disc herniations; treatment modalities were non operative or operative (discectomy). Significant improved in physical function, bodily pain and disability scales were seen at even 4 years postoperatively.

Figures A and B show the axial and sagittal sequences of a T2-weighted MRI of the lower lumbar spine demonstrating a large L5/S1 right sided para-central disc herniation.

Incorrect answers
Answers 1, 2, 3: Many (> 90%) disc herniations have a self-limited natural history; the symptoms may be alleviated by bedrest and activites as tolerated, administration of anti-inflammatories or GABA analogs and completion of physical therapy. For symptoms that persist greater than 6 weeks and are disabling, despite attempted nonoperative measures, surgery is indicated.
Answers 5: Completion of a discectomy and instrumented fusion is not indicated in this patient as there is no evidence of degenerative disease or spondylolisthesis.