What is the next step in managing a 46-year-old female with radicular pain in the L5 distribution and an MRI-confirmed disc protrusion at L5?

Management of L5 Radicular Pain with Disc Protrusion

For a 46-year-old female with L5 radicular pain and MRI-confirmed disc protrusion, the next step should be conservative management for 6 weeks, including pain control with NSAIDs/acetaminophen, physical therapy focusing on core strengthening and gentle stretching, and activity modification. 1

Initial Conservative Management (First 6 Weeks)

Conservative management is the appropriate first-line approach unless severe neurological compromise is present. This includes:

1. Pain Management:

   • NSAIDs and acetaminophen for pain control 1
   • Consider gabapentin for neuropathic pain with radiculopathy 1
   • Avoid bed rest; advise reactivation 2

2. Physical Therapy:

   • Postural education
   • Gentle stretching
   • Core strengthening exercises
   • Activity modification 1
   • Heat/cold therapy as needed

3. Self-Management Education:

   • Provide comprehensive information on self-management strategies
   • Direct support and reinforcement are usually needed 2

Assessment at 2 Weeks

If no improvement or deterioration occurs after 2 weeks, assess severity and impact using the STarT Back tool 2:

• Low Risk on STarT Back: Continue current management
• High Risk on STarT Back: Refer for biopsychosocial assessment 2

Follow-up at 4-6 Weeks

If symptoms persist after 4-6 weeks of conservative management:

1. Consider Transforaminal Epidural Steroid Injection (TFESI):

   • Appropriate for patients with persistent radicular symptoms consistent with imaging findings 1
   • TFESI has shown effectiveness regardless of disc herniation type or location 3
   • Image guidance (fluoroscopy) is essential for safety and efficacy 2

2. Referral to Spine Specialist:

   • If symptoms persist or worsen despite conservative management 1
   • Should be considered not later than 3 months (earlier if pain is severe) 2

Surgical Considerations

Surgery should only be considered in specific circumstances:

• Pain control unsuccessful after adequate conservative management
• Motor deficit greater than grade 3
• Radicular pain associated with foraminal stenosis
• Cauda equina syndrome 1

For routine disc herniations, lumbar discectomy without fusion is the surgical procedure of choice 1.

Important Considerations and Pitfalls

1. Avoid Premature Imaging:

   • MRI is not recommended at primary care level for routine spinal pain
   • MRI should be requested only by clinicians able to interpret the images 2

2. Red Flags Requiring Immediate Attention:

   • Progressive neurological deficits
   • Cauda equina syndrome symptoms
   • Motor weakness greater than grade 3
   • Severe or worsening radicular pain 1

3. Prognosis Education:

   • Most patients experience significant improvement within 4-12 weeks 1
   • Up to 75% of patients with acute radiculopathy may experience spontaneous improvement 1
   • Surgery may only be necessary if pain persists beyond 3 months or neurologic deficits develop/worsen 4

4. Avoid Vertebral Axial Decompression (VAX-D):

   • Has potential to cause sudden deterioration requiring urgent surgical intervention 5

The management approach should follow this stepped care algorithm, with regular assessment of treatment response and progression to more invasive options only when conservative measures fail to provide adequate relief.