Management Strategies for Lumbar Disc Herniation

Pradeep Chopra, MD

Back pain sends more people to the doctor than any other condition except the common cold, but similar symptoms shared by several different conditions make it difficult for many physicians to properly diagnose a lumbar disc herniation.

Lumbar disc herniation (LDH) typically presents with lower back pain that radiates down one leg, and is often accompanied by numbness or tingling in the foot. Physicians who observe those symptoms often try to confirm with an X-ray or MRI, but scans rarely provide conclusive proof and can even mislead doctors making a differential diagnosis. “Many disc herniations seen on MRI may not be the reason for the patient’s pain,” says Pradeep Chopra, MD, Director of the Interventional Pain Management Center of Rhode Island and Assistant Professor at Brown University Medical School. “On the other hand, a patient may present with spinal pain and a normal MRI. X-rays have no value in diagnosing lumbar disc pain.”

"Many disc herniations seen on MRI may not be the reason for the patient’s pain. On the other hand, a patient may present with spinal pain and a normal MRI. X-rays have no value in diagnosing lumbar disc pain."

—Pradeep Chopra, MD Director of the Interventional Pain Management Center of Rhode Island

The best method for diagnosing LDH is to get a full history and perform a physical examination designed to distinguish lumbar disc herniation from similar ailments. For example, to separate LDH from sacroiliac (SI) joint dysfunction, which makes the piriformis spasm and creates pain in the back and leg, doctors can sit the patient down, place the ankle of the ailing leg on the opposite knee, and press down on the bent leg. This will increase pain caused by the SI joint but do nothing to an LDH.

Another LDH impostor is lumbar facet joint pain, which also creates pain in the back and down one leg. Unlike LDH, however, lumbar facet joint pain rarely affects any region of the leg below the knee and almost never creates the sort of numbness or tingling in the foot that often comes with LDH.

Problems with the hip joint, likewise, create pain in the back and leg, but they distinguish themselves from LDH by responding dramatically to changes in position. The instant the patient takes weight off an injured hip, the pain subsides. LDH pain remains relatively constant in all positions.

There are, however, several tests that can identify LDH. A straight leg test—holding the affected leg straight at the knee and bending it at the hip while the patient lies flat on his or her back‑‑will generally trigger pain in an L5 herniation. The femoral extension test—bending the knee and then the hip of a patient who is lying prone—will generally trigger pain in a herniation low in the spine.

When treating LDH, start conservatively, but also know when to refer

Once diagnosed, the proper initial treatment for most LDH is a combination of analgesics, anti-inflammatory medications, and physical therapy. “If it’s just pain, non-specialists should start with three or four weeks of standard treatment. However, if there is motor loss or sensory loss, patients need to see a specialist. Lumbar disc herniations can lead to foot drops, weakness in the lower extremities, and bowel or bladder problems, all of which can be serious,” says Nirav K. Shah, MD, FACS, a neurosurgeon who specializes in complex spinal surgery and intracranial tumor/radiosurgery at Princeton Brain and Spine Care.

For less severe cases, a few days of rest may be helpful at the outset to help decrease swelling, but extended rest rarely helps and often hurts by allowing core muscles to atrophy. Instead, patients should pursue exercise programs that maintain range of motion and strengthen core muscles. “The idea, as with many conditions, is to begin with the most conservative treatments and work upward. Unless you’re a specialist, you probably shouldn’t be making spinal injections at a patient’s first visit,” says Tarun Jolly, MD, CEO of Louisiana Pain Specialists and Co-director of Pain Management at the Department of Anesthesiology in LSU Health Sciences Center.

Physicians need not see patients every week to monitor progress; a follow-up appointment after three or four weeks of medication and exercise is generally enough. They should also provide patients with literature that explains what they should be feeling if treatment works and what signs and symptoms warrant early follow-up.

This relatively conservative course will work in most cases, eliminating the pain entirely or at least putting it on a path toward elimination and making it manageable. When conservative treatment fails, physicians should refer patients to a pain management specialist or to a spinal surgeon.