How should I manage an adult patient with a lumbar CT showing a broad‑based disc protrusion and annular fissure causing low back pain without severe neurological deficits?

Management of Lumbar Disc Protrusion with Annular Fissure

Begin with at least 6 weeks of conservative management without imaging, as disc protrusions and annular fissures are present in up to 43% of asymptomatic adults and most disc herniations show spontaneous reabsorption by 8 weeks. 1, 2

Initial Conservative Management (0–6 Weeks)

Do not order imaging during this period unless red-flag features develop. 1, 2

Non-Pharmacologic Interventions

• Encourage the patient to remain active rather than bed rest, as activity modification with continued movement is more effective than complete rest for acute low back pain 1, 2
• Initiate physical therapy immediately, focusing on patient-centered, goal-oriented exercises without waiting for imaging results 1
• Apply heat therapy for short-term symptomatic relief 1
• Educate the patient that disc protrusions and annular fissures are extremely common in asymptomatic individuals and do not necessarily correlate with pain—imaging abnormalities are present in approximately 43% of asymptomatic adults around age 62 1, 3
• Reassure the patient that most disc herniations demonstrate spontaneous reabsorption or regression by approximately 8 weeks after symptom onset 1, 2, 4

Pharmacologic Management

• Prescribe NSAIDs as first-line analgesic therapy for pain control 1, 2
• Consider muscle relaxants for associated muscle spasms if present 2
• Reserve short-term opioids only for severe, disabling pain and use judiciously 2

Red-Flag Screening

Obtain urgent MRI immediately if any of the following develop at any time: 1, 2

• Cauda equina syndrome signs: saddle anesthesia, bilateral leg weakness, urinary retention/incontinence, loss of anal sphincter tone 1, 2
• Progressive motor deficits or rapidly worsening neurologic symptoms 2
• Fever, recent invasive spinal procedure, intravenous drug use, or immunosuppression (suggesting infection) 1, 2
• Known cancer, unexplained weight loss, or age > 50 with new-onset pain (suggesting malignancy) 2
• Significant trauma, osteoporosis, or prolonged corticosteroid use (suggesting fracture) 2

Neurologic Examination

Perform a focused neurologic examination to classify the patient and guide management: 2

• Test motor strength: hip flexion (L2), knee extension (L3-L4), ankle dorsiflexion (L4-L5), great-toe extension (L5), ankle plantarflexion (S1) 2
• Assess dermatomal sensory function to detect nerve-root involvement 2
• Evaluate deep-tendon reflexes: patellar (L4) and Achilles (S1) 2
• Perform straight-leg-raise test to identify radiculopathy 2
• Check for saddle anesthesia and anal sphincter tone if cauda equina is suspected 2

If the neurologic exam is normal and no red flags are present, the patient has nonspecific low back pain and does NOT require imaging—proceed with conservative management only. 2

Timing for MRI Consideration

MRI lumbar spine without contrast becomes appropriate only after ≥ 6 weeks of failed conservative therapy in patients who are potential surgical candidates or candidates for epidural steroid injection. 1, 2

Rationale for Delayed Imaging

• Routine imaging provides no clinical benefit for patients without red flags and increases healthcare utilization (more injections, surgeries, disability claims) without improving outcomes 1
• Disc protrusions, annular fissures, and degenerative changes are extremely common in asymptomatic individuals—84% of patients with pre-symptomatic imaging abnormalities showed unchanged or improved findings after symptom onset 1
• Thoracic disc abnormalities such as herniations, bulges, and annular fissures are common in asymptomatic patients, and morphologic imaging changes do not correlate with pain 5
• Meta-analysis demonstrates that while disc protrusion and degeneration are more prevalent in symptomatic adults ≤ 50 years old (OR 2.65 and 2.24 respectively), annular fissures show no significant association with low back pain (OR 1.79,95% CI 0.97-3.31, P = 0.06) 6
• There is no correlation between the side of an annular tear and the side of the patient's pain, raising questions about the validity of attributing symptoms to specific imaging findings 7

Interventional Options After Failed Conservative Therapy

If symptoms persist beyond 6 weeks despite optimal conservative management: 2, 8

• Epidural steroid injections may be considered for radiculopathy specifically, with fluoroscopic guidance being the gold standard for targeted interlaminar or transforaminal injections 2
• For chronic discogenic low back pain refractory to conservative care, biacuplasty or cooled radiofrequency ablation can be used as therapeutic options 8
• Radiofrequency ablation may be considered weakly for chronic low back pain with suspected facet involvement after positive medial branch blocks 2
• Pressure-controlled provocative discography remains the current diagnostic standard for confirming discogenic pain, though it is controversial 8, 9

Surgical Considerations

Surgery becomes appropriate only for: 2

• Persistent radicular symptoms despite ≥ 6 weeks of noninvasive therapy 2
• Documented nerve root compression on MRI that correlates with clinical symptoms 2
• Symptoms that significantly limit function after biopsychosocial assessment 2

Discectomy alone (open, microtubular, or endoscopic) is the appropriate surgical intervention—70% of patients undergoing discectomy alone return to work, compared to only 45% with fusion added. 2

Lumbar fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy, as it increases complexity, surgical time, and complication rates without proven medical necessity. 2

Critical Pitfalls to Avoid

• Do not order CT or MRI before 6 weeks unless red flags are present—imaging abnormalities do not correlate with symptoms in most cases 1, 2, 3
• Do not assume that a broad-based disc protrusion or annular fissure seen on imaging is the source of pain—these findings are extremely common in asymptomatic adults 5, 1, 3, 6
• Do not prescribe bed rest—encourage activity as tolerated 1, 2
• Do not delay initiation of conservative therapy while awaiting imaging decisions 1
• Do not delay specialist referral beyond 3 months for persistent symptoms, as this can lead to prolonged disability 2
• Avoid further imaging or invasive testing unless new objective findings emerge, as this reinforces illness behavior and increases healthcare utilization without benefit 3

Reassessment Timeline

• At 2 weeks: Review symptom severity; if disabling symptoms persist, consider earlier specialist referral 1
• At 6 weeks: If no improvement with conservative measures, obtain MRI for patients who may be surgical candidates 1, 2
• At 3 months: If symptoms remain despite optimal conservative care, arrange referral to a spine specialist 2