What is the best course of treatment for a patient with left-sided radiculopathy involving the L1-S1 dermatome, found to have a broad-based posterior disc protrusion at the L4-L5 level on CT (Computed Tomography) scan of the lumbosacral spine, with a history of possible degenerative disc disease, osteoporosis, or previous back injuries?

Treatment Approach for L4-L5 Disc Protrusion with Left L5 Radiculopathy

Begin with a structured 6-12 week conservative management program before considering any surgical intervention, as the majority of disc herniations show spontaneous reabsorption and clinical improvement without surgery. 1, 2

Initial Conservative Management (First-Line Treatment)

The patient requires comprehensive nonoperative treatment consisting of:

• Pharmacologic management with oral analgesics combined with structured physical therapy focusing on core strengthening and stabilization exercises 2, 3
• Cognitive behavioral therapy component to address pain catastrophizing and unhelpful beliefs about the condition 1, 2
• Activity modification while maintaining normal activities of daily living that do not cause harm 1
• Minimum duration of 6-12 weeks of this structured conservative care before considering escalation 2

Critical Evidence Supporting Conservative Approach

• Disc herniations frequently resolve spontaneously: A prospective study demonstrated that 43% of disc herniations completely resolved and 36% improved on follow-up imaging after conservative treatment, with patients remaining symptom-free for an average of 30.4 months 4
• Most disc herniations show reabsorption by 8 weeks after symptom onset 1
• The imaging findings (broad-based disc protrusion at L4-L5) are common in asymptomatic individuals, with disc protrusion prevalence ranging from 29-43% in people without back pain 1

Escalation to Interventional Treatment

If symptoms persist or worsen after 6 weeks of optimal conservative management:

• Fluoroscopically guided epidural steroid injection may be considered for patients who fail initial conservative measures 3
• Selective nerve root blocks (diagnostic, not therapeutic) can establish concordance between imaging findings and clinical symptoms 2

Surgical Consideration Criteria

Surgery should only be considered if the patient meets ALL of the following criteria:

• Failure of 6-12 weeks of structured conservative therapy including physical therapy with cognitive behavioral component 1, 2
• Persistent or progressive neurologic deficits (such as foot drop or progressive weakness) 2
• Concordant imaging and clinical findings confirmed by diagnostic selective nerve root blocks if needed 2
• Patient is an appropriate surgical candidate with optimized medical comorbidities 2

Surgical Approach When Indicated

• Standard open discectomy/hemilaminectomy remains the established surgical approach with good long-term outcomes for lumbar disc herniation with radiculopathy 2, 5
• Long-term surgical outcomes are favorable: A 10-15 year follow-up study showed high rates of good results with standard discectomy, minimal recurrences, and few patients suffering from leg pain 5

Important Clinical Caveats

• The extensive dermatome involvement (L1-S1) described in the history does NOT match the imaging finding of isolated L4-L5 disc protrusion affecting the L5 nerve root - this discordance requires careful clinical correlation and consideration of alternative diagnoses 6, 7
• Systematic evaluation of the entire lumbosacral spine including sacrum and conus medullaris is recommended, as neoplastic disease can present as classic disc herniation 7
• MRI is superior to CT for evaluating soft tissue pathology and should be obtained if not already performed, particularly given the atypical clinical presentation 1
• Early imaging and surgery are associated with increased healthcare utilization without improved outcomes compared to conservative management 1