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Management of Acute Lumbar Disk Herniation Reviewed
http://www.medscape.com/viewarticle/581578?sssdmh=dm1.391957&src=nldne
October 6, 2008 — Patient preference and severity of the disability from acute lumbar disk pain should be considered when treatment modalities are chosen, according to a review providing recommendations for treating and diagnosing this condition, reported in the October 1 issue of American Family Physician.
“Low back pain is one of the most common reasons patients present to primary care practices, and is a leading cause of job-related disability in the United States,” write David S. Gregory, MD, from Lynchburg Family Medicine Residency in Lynchburg, Virginia, and colleagues from the University of Virginia in Charlottesville. “Acute lumbar disk herniation can produce severe, function-limiting pain that usually resolves with conservative management. Because a small proportion of lumbar disk herniations can result in serious disability and progressive neurologic dysfunction, surgical treatments are sometimes indicated.”
Acute lumbar disk herniation is the most common cause of sciatica, which is defined as pain originating in the lower back and radiating down the posterior or lateral thigh. The differential diagnosis for radiating acute lumbar pain also includes cauda equina syndrome, facet arthropathy, greater trochanteric bursitis, iliotibial band syndrome, lumbar disk herniation, meralgia paresthetica, piriformis syndrome, pseudoclaudication, sacroiliitis, spinal neoplasms, spinal stenosis, and vertebral fracture or infection.
Findings that are more specific for sciatica from lumbar disk herniation include pain that is worse in the leg vs the back; typical dermatomal distribution of pain, numbness, or other neurologic symptoms and signs; and pain that is worse with the Valsalva maneuver during coughing, sneezing, or straining.
“Red-flag” findings should alert the clinician to spinal disorders other than acute lumbar disk herniation, some of which need to be evaluated and treated urgently. Fecal incontinence, saddle anesthesia, and/or urinary retention may suggest cauda equina syndrome. A history of immunosuppression, intravenous drug use, or unexplained fever may herald spinal infection, and chronic steroid use may predispose to fracture or infection.
Fracture is suggested by osteoporosis or by a significant traumatic injury at any age, whereas patients who are older than 50 years and sustain a mild traumatic injury may have a fracture or neoplasm. Cancer is even more likely if there is a history of cancer-associated symptoms, such as unexplained weight loss.
Focal neurologic deficit, progressive or disabling symptoms, and/or lack of improvement after 6 weeks of conservative management may reflect any of the above urgent causes of radiating acute lumbar pain.
Once cauda equina syndrome, epidural abscess, fracture, malignant neoplasm, and other emergent causes of sciatica are ruled out, then a 6-week trial of conservative management for presumed lumbar disk disease is warranted.
During the 6-week trial, patients should be counseled to remain active. Most patients with lumbar disk herniations have symptom improvement with conservative management during this 6-week period. However, imaging and invasive procedures may be considered if symptoms persist after 6 weeks or if neurologic function worsens.
Evidence to date suggests that after 2 years, there is no difference in outcomes between surgical and conservative treatment. Therefore, choice of treatment modalities should be guided by patient preference and the severity of the disability from the pain.
When the anatomic level of disk herniation on imaging studies correlates with physical findings of nerve root irritation at the same level, and when the result of a straight-leg raise test is positive, surgical diskectomy may lead to symptom improvement or resolution more quickly than continued conservative management. Epidural steroid injections may also be effective for short-term symptomatic relief.
The goal of surgery is to relieve nerve root compression or irritation from herniated disk material. Two frequently used techniques are open diskectomy and microdiskectomy, which entails disk removal with visualization using a surgical microscope. Outcomes have been shown to be similar with both techniques.
Key recommendations for clinical practice, most of which are rated level of evidence A on the basis of randomized controlled trials and/or systematic reviews, are as follows:
* Clinicians should encourage patients with acute lumbar pain to stay active.
* Although nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants may be helpful for nonspecific low back pain, they have not been extensively studied for pain relief from lumbar disk herniation (level of evidence B, based on systematic reviews and conflicting randomized controlled trials).
* For treatment of pain from lumbar disk herniation, systemic steroids are no better than placebo.
* In the short-term, epidural steroid injections may modestly reduce pain from acute lumbar disk herniation. However, they do not affect long-term outcomes.
* In the absence of red-flag findings, patients with sciatica should be treated conservatively for up to 6 weeks before undergoing imaging studies and considering surgical intervention.
* Diskectomy may offer faster clinical relief in selected patients with pain from lumbar disk herniation that does not improve after 6 weeks of conservative management.
* Long-term outcomes with diskectomy are similar to those obtained with conservative or nonsurgical management.
“The natural history of lumbar disk herniation reveals that large herniations typically reabsorb with time, and symptoms will improve in most patients with conservative management alone,” the review authors conclude. “If imaging correlates well, surgical referral should be offered, but only as a potential means of expediting improvement in pain and disability over conservative management alone. Patients should be informed that the expected amount of pain and disability two years after surgery will be indistinguishable from the pain two years after prolonged conservative management.”
The review authors have disclosed no relevant financial relationships.
Am Fam Physician. 2008;78:835-842.
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
1. Describe the symptoms of sciatica associated with lumbar disk herniation.
2. Report the treatment options of acute lumbar disk herniation.
Clinical Context
Low back pain is one of the most common reasons patients present to primary care offices. Sciatica is defined as pain originating in the lower back and radiating down the posterior or lateral thigh. In the absence of red-flag findings, the most common cause of sciatica is lumbar disk herniation. However, sciatic pain is not specific for lumbar disk herniation. Symptoms that increase the specificity of sciatica from lumbar disk herniation includes pain that is worse in the leg vs the back, a typical dermatomal distribution of neurologic symptoms, and pain that is worse with the Valsalva maneuver. Overall, acute lumbar disk herniation can produce severe, function-limiting pain.
The aim of this article was to review the evaluation and treatment choices of acute lumbar disk pain.
Study Highlights
* Acute lumbar disk herniation is the most common cause of sciatica.
* When lumbar disk herniation is suspected, the physical examination should include a full examination of the pelvis and lower extremities, including a neurologic examination to evaluate sensation, strength, and reflexes; and provocative tests, such as the straight-leg raise.
* Although not specific, the straight-leg raise is the most sensitive test for lumbar herniation, with a negative result indicating against lumbar disk herniation.
* If red-flag findings are absent, a patient with sciatica should try conservative management for up to 6 weeks before obtaining imaging studies and considering surgical approaches (evidence rating, A).
* Patients should be advised to stay active (evidence rating, A).
* Nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants may be effective for nonspecific low back pain but have not been extensively studied with lumbar disk herniation pain (evidence rating, B).
* Systemic steroids are no better than placebo in the treatment of lumbar disk herniation pain (evidence rating, A).
* If symptoms persist after 6 weeks, or if there is worsening neurologic function, imaging studies and invasive procedures may be considered.
* Computed tomography and magnetic resonance imaging provide similar sensitivity and specificity for lumbar disk herniation, although magnetic resonance imaging provides a more detailed evaluation of the nerve roods and soft tissues of the spine.
* Most patients with lumbar disk herniations improve after 6 weeks.
* Because there is no difference in outcomes between surgical and conservative treatment after 2 years, patient preference and the severity of the disability from pain should be considered when treatment modalities are chosen.
* Invasive nonsurgical treatments involve steroid injections into the epidural space or herniated disk. Epidural steroid injections for acute lumbar disk herniation may modestly improve pain in the short-term but do not affect long-term outcomes (evidence rating, A).
* The indications for emergent surgical intervention for sciatica include cauda equina syndrome, epidural abscess, or severe and progressive neuromotor deficits.
* Selected patients with lumbar disk herniation pain that is not improved after 6 weeks of conservative management may benefit from diskectomy for faster clinical relief (evidence rating, A).
* Compared with surgical diskectomy, microdiskectomy, which involves disk removal with the aid of a surgical microscope, has similar surgical outcomes.
* Diskectomy has similar long-term outcomes as conservative or nonsurgical management (evidence rating, A).
Pearls for Practice
* The specificity of sciatica from lumbar disk herniation increases with symptoms that include pain that is worse in the leg vs the back, a typical dermatomal distribution of neurologic symptoms, and pain that is worse with the Valsalva maneuver.
* Patients with sciatica should try conservative management for up to 6 weeks before obtaining imaging studies and considering surgical approaches. Selected patients with lumbar disk herniation pain that does not improve after 6 weeks of conservative management may benefit from diskectomy for faster clinical relief.
