Does a patient with a suspected large left central extruded disc fragment extending inferiorly from the L4-L5 (Lumbar 4-Lumbar 5) disc space, with probable replacement of the left lateral recess and possible contact of the left L5 (Lumbar 5) nerve root, need to see a neurosurgeon?

Neurosurgical Referral for L4-L5 Disc Herniation with Nerve Root Compression

Yes, this patient should be referred to a neurosurgeon due to the large extruded disc fragment at L4-L5 with nerve root compression, as this presentation indicates potential need for surgical intervention.

Imaging Findings and Clinical Significance

The imaging findings describe:

• Large left central extruded disc fragment at L4-L5
• Inferior extension from the disc space
• Probable replacement of left lateral recess
• Possible contact with the left L5 nerve root

These findings represent significant pathology that warrants neurosurgical evaluation for several reasons:

• Extruded disc fragments (as opposed to contained herniations) have a higher likelihood of requiring surgical intervention 1
• Nerve root compression can lead to progressive neurological deficits if not properly addressed
• The large size and central location with lateral extension suggests potential for worsening compression

Decision Algorithm for Neurosurgical Referral

Indications for Immediate Neurosurgical Referral:

1. Progressive neurological deficits - If the patient shows worsening motor weakness, sensory changes, or reflex abnormalities
2. Cauda equina syndrome - Urinary retention (90% sensitive for cauda equina) or bowel/bladder dysfunction 1
3. Severe, uncontrolled pain despite appropriate conservative management

Indications for Urgent Neurosurgical Referral (within 1-2 weeks):

1. Large extruded disc fragment with nerve root compression (as in this case)
2. Significant motor deficit (grade 3 or worse) 1
3. Persistent radicular symptoms consistent with imaging findings

Management Considerations

Pre-Neurosurgical Consultation Management:

• Pain control with NSAIDs as first-line treatment 1
• Activity modification without complete bed rest
• Consider gabapentin for neuropathic pain with radiculopathy 1

What the Neurosurgeon Will Evaluate:

1. Correlation between clinical symptoms and imaging findings
2. Severity and progression of neurological deficits
3. Response to conservative management
4. Surgical candidacy based on overall health status

Surgical vs. Conservative Management

The American College of Physicians recommends surgery when 1:

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

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

Important Caveats and Pitfalls

1. Don't delay referral with progressive deficits - While some disc herniations can resolve spontaneously 2, waiting too long with progressive symptoms can lead to permanent neurological damage

2. Don't assume all disc herniations require surgery - The neurosurgeon will determine if surgery is indicated based on clinical presentation and imaging correlation

3. Beware of atypical presentations - Disc herniations can sometimes cause remote radicular symptoms not directly related to the level of compression 3

4. Consider sphincter dysfunction - Some patients with L5-S1 disc herniations may present with sexual and sphincter dysfunction even without pain or muscle weakness 4

The decision for surgical intervention will ultimately be made by the neurosurgeon after a comprehensive evaluation, but given the imaging findings of a large extruded fragment with nerve root compression, neurosurgical consultation is clearly indicated in this case.