Who should a patient with disc herniation see?

Management of Patients with Disc Herniation

Patients with disc herniation should initially be referred to a neurologist or interventional physiatrist for conservative management, with surgical referral only when conservative measures fail or specific indications are present.

Initial Management Pathway

First-Line Treatment

• Patients with disc herniation typically present with radicular symptoms consistent with spinal nerve compression and sometimes low back pain 1, 2
• Initial management should include:
  • Oral analgesic medication
  • Activity modification
  • Physical therapy 2

Second-Line Treatment

• For patients who don't respond adequately to first-line treatments:
  • Fluoroscopically guided contrast-enhanced epidural steroid injections 2
  • Continued physical therapy with focus on core strengthening 2, 3

Surgical Referral Indications

• Surgery (typically discectomy) should be considered only when:
  • Nonoperative treatments fail to provide adequate relief 2, 3
  • Progressive neurological deficits are present 3
  • Cauda equina syndrome develops 3
  • Severe, disabling pain persists despite conservative management 1, 3

Specialist Referral Decision Algorithm

Neurosurgical/Orthopedic Spine Surgeon Referral

• Indicated for:
  • Failed conservative management (typically after 6-12 weeks) 2, 4
  • Recurrent disc herniations, especially with instability or chronic axial low back pain 1
  • Manual laborers with significant chronic axial back pain who may benefit from fusion 1
  • Patients with demonstrated preoperative instability 1

Important Considerations for Surgical Management

• Lumbar fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy 1
• Fusion should be considered only in specific circumstances:
  • Patients with significant chronic axial back pain 1
  • Manual laborers (who show better long-term work retention with fusion) 1
  • Patients with severe degenerative changes 1
  • Patients with instability associated with radiculopathy 1
  • Recurrent disc herniations with instability or chronic axial low back pain 1

Common Pitfalls in Management

• Rushing to surgical intervention before adequate trial of conservative measures 2, 4
• Performing fusion during routine discectomy, which increases:
  • Surgical complexity
  • Operating time
  • Potential complications
  • Cost 1
• Failing to recognize red flags requiring urgent surgical evaluation:
  • Cauda equina syndrome
  • Progressive neurological deficits 3
• Not considering the patient's occupation and physical demands when planning treatment 1

Special Considerations

• Manual laborers may benefit from fusion at the time of discectomy:
  • 89% of fusion patients vs. 53% of discectomy-only patients maintain work activities at 1 year 1
  • However, return to work is faster with discectomy alone (12 weeks vs. 25 weeks) 1
• Patients with recurrent disc herniations show good outcomes with fusion:
  • 92% improvement rate and 90% satisfaction with posterior decompression and fusion 1
• The natural history of lumbar disc herniation is generally favorable, with many patients improving with conservative management alone 4