Where to Refer Patients with Disc Herniation
Refer patients with disc herniation initially to a neurologist or interventional physiatrist for conservative management, reserving neurosurgical or orthopedic spine surgeon referral for those with progressive neurologic deficits, failed conservative treatment (typically after 4-6 weeks), cauda equina syndrome, or specific surgical indications. 1
Initial Referral Strategy
Most patients with disc herniation should begin with non-surgical specialist referral because the natural history is favorable, with most cases improving within 4-6 weeks of conservative management 2, 3. The appropriate initial referrals include:
- Neurologist or interventional physiatrist for conservative management including medications, physical therapy, and potentially epidural steroid injections 1
- Physical medicine and rehabilitation specialist for comprehensive non-operative care 4
Do not routinely refer to spine surgeons initially unless red flags are present, as imaging and surgical consultation in uncomplicated cases do not improve outcomes and increase costs 2.
When to Refer to Neurosurgery or Orthopedic Spine Surgery
Urgent/Emergent Surgical Referral (Same Day)
Refer immediately for:
- Cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia, bilateral leg weakness) - this is a surgical emergency 2, 3, 5
- Progressive neurologic deficits including worsening motor weakness (especially grade 3 or less) 2, 3
- Severe or rapidly progressive motor deficits 2
Non-Urgent Surgical Referral (After Conservative Trial)
Refer to spine surgeon after 4-6 weeks of failed conservative management when:
- Persistent radicular symptoms despite noninvasive therapy, making the patient a candidate for discectomy or epidural steroid injection 2
- Severe, disabling pain that persists despite adequate conservative treatment 1
- Recurrent disc herniation with instability, chronic axial low back pain, or radiographic degenerative changes 2, 1
Special Populations Requiring Surgical Consultation
Consider earlier or specific surgical referral for:
- Manual laborers with significant chronic axial back pain in addition to radiculopathy - these patients may benefit from fusion at time of discectomy (89% vs 53% maintained work activities at 1 year with fusion vs discectomy alone) 2, 1
- Patients with demonstrated preoperative instability on imaging 1
- Radiculopathy with foraminal stenosis causing persistent radicular pain 3
Imaging Before Referral
Obtain MRI (preferred) or CT only if the patient is a potential surgical candidate - do not image routinely in the first 4-6 weeks unless red flags are present 2. Specifically:
- Immediate imaging (MRI preferred) for suspected cauda equina syndrome, cancer with impending cord compression, vertebral infection, or progressive neurologic deficits 2
- Delayed imaging (after 4-6 weeks) for persistent symptoms in surgical candidates 2
- No routine imaging for uncomplicated radiculopathy in the first month, as it does not improve outcomes 2
Common Pitfalls to Avoid
- Do not refer all disc herniations to surgeons - most resolve with conservative care and routine fusion is NOT recommended for isolated disc herniation 2, 1
- Do not delay imaging in red flag cases - delayed diagnosis of cauda equina syndrome or cord compression leads to poorer outcomes 2
- Do not assume all back pain with radiculopathy needs surgery - the natural history favors spontaneous improvement in most cases 2, 6, 3
- Do not order MRI in the first 4-6 weeks unless red flags present - this increases costs without improving outcomes 2