What is the appropriate initial management for a 62‑year‑old female with right lumbar radiculopathy and MRI showing a moderate posterior‑left paracentral L3‑L4 disc protrusion causing thecal sac indentation, bilateral traversing nerve compression (greater on the left), a narrowed spinal canal (AP 5.4 mm) and mild bilateral foraminal narrowing?

Initial Management of L3-L4 Disc Protrusion with Radiculopathy

Begin with 6 weeks of conservative therapy combining pharmacologic treatment (NSAIDs, neuropathic pain medications) and nonpharmacologic interventions (physical therapy, remaining active), as this patient already has diagnostic imaging and meets criteria for a trial of medical management before considering surgical intervention. 1

Conservative Management Framework

First-Line Treatment (0-6 Weeks)

• Pharmacologic therapy should include NSAIDs for inflammation and consider neuropathic pain medications (gabapentin, pregabalin) for radicular symptoms 2
• Physical therapy with emphasis on core strengthening and maintaining activity levels rather than bed rest 1
• Avoid prolonged rest as remaining active improves outcomes in lumbar radiculopathy 1

Clinical Monitoring During Conservative Trial

Watch for "red flag" symptoms that would necessitate urgent surgical evaluation:

• Progressive motor weakness (particularly foot drop or quadriceps weakness) 2
• New-onset bowel or bladder dysfunction (cauda equina syndrome) 1
• Saddle anesthesia or perianal numbness 1
• Progressive neurologic deficits despite conservative care 1

When to Consider Surgical Referral

If symptoms persist or progress after 6 weeks of optimal conservative management, surgical consultation is appropriate. 1

Imaging Features Predicting Conservative Treatment Failure

Your patient has several MRI findings associated with higher surgical risk 3:

• Moderate disc protrusion (extrusions and protrusions have higher failure rates than bulges) 3
• Paracentral location (more laterally located discs predict conservative failure) 3
• Spinal canal narrowing (5.4 mm AP dimension indicates significant stenosis) 3
• Bilateral foraminal narrowing with nerve compression 3

Important Clinical Caveat

The discordance between imaging (left > right nerve compression) and symptoms (right radiculopathy) requires careful attention. 4

• Disc herniations can occasionally cause non-adjacent radicular symptoms 4
• Ensure physical examination findings correlate with the right L3 or L4 nerve root distribution 2
• If symptoms don't match imaging, consider whether conservative therapy is targeting the correct level 4

Avoiding Unnecessary Prolonged Conservative Management

Given the moderate stenosis (5.4 mm canal), bilateral foraminal narrowing, and moderate disc protrusion, do not extend conservative therapy beyond 6-8 weeks if symptoms are not improving. 3

• Larger fragment size, higher-grade disc degeneration, and more severe canal/foraminal stenosis predict conservative failure 3
• Unnecessarily prolonged conservative management beyond 8 weeks in patients with these features delays appropriate surgical intervention 3

Surgical Candidacy Criteria

Refer for surgical evaluation if the patient has: 1

• Persistent or progressive symptoms after 6 weeks of optimal medical management 1
• Functionally limiting radiculopathy affecting quality of life 1
• Objective neurologic deficits on examination 2
• MRI-confirmed nerve root compression correlating with clinical symptoms 1

Additional Imaging Considerations

• No additional imaging is needed as MRI has already been obtained and is the gold standard for surgical planning 1
• CT myelography may be complementary if surgical planning requires better visualization of bony anatomy or if MRI is contraindicated 1
• Flexion-extension radiographs may be useful if spondylolisthesis or segmental instability is suspected 1