Herniated discMANAGEMENT

MUSCULOSKELETAL AND RHEUMATOLOGIC PRESENTATIONS · 12 SECTIONS

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518 items

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01Approach to the Critical Patient/attcp38

Immediate priorities

›Herniated disc is usually a non-emergent diagnosis, but three time-critical syndromes must be excluded before disposition

›Cauda equina syndrome from a large central lumbar herniation

›Bilateral sciatica, saddle sensory loss, urinary retention with overflow incontinence, reduced anal tone, sexual dysfunction

›Progressive or bilateral lower-limb motor weakness

›Acute cervical or thoracic disc herniation with spinal cord compression and myelopathy

›Gait instability, hand clumsiness, hyperreflexia, Hoffmann and Babinski signs, a sensory level

›Spinal epidural abscess or haematoma presenting as acute radiculopathy

›Fever, focal spinal tenderness, immunosuppression, injection drug use, anticoagulation, recent spinal procedure

›Establish the onset time of any neurological deficit, because decompression within 24 to 48 hours of cauda equina onset improves bladder and ambulatory recovery

›Baseline neurological examination including perineal sensation, anal tone and post-void residual before giving opioids or sedation that will confound serial examination

›Escalate to the resuscitation area for acute quadriparesis, diaphragmatic weakness from a C3 to C5 level, or hypotension with bradycardia suggesting neurogenic shock

Time-critical diagnoses to exclude

›Cauda equina syndrome

›Emergent non-contrast MRI of the whole lumbosacral spine

›Emergent spine surgery referral, neurosurgery or orthopaedic spine, once confirmed

›Bladder catheterisation for retention and accurate output measurement

›Malignant spinal cord or cauda equina compression

›Known primary malignancy, unrelenting night pain, weight loss, thoracic-level pain

›Dexamethasone plus urgent MRI of the whole spine, with radiation oncology and spine surgery involvement

›Spinal epidural abscess

›The triad of fever, spinal pain and neurological deficit is present in a minority; use risk factors and inflammatory markers to raise suspicion

›Blood cultures before antibiotics, then empirical vancomycin plus an antipseudomonal beta-lactam, and emergent MRI with contrast

›Spinal epidural haematoma

›Anticoagulant or antiplatelet therapy, recent neuraxial procedure, coagulopathy

›Reverse anticoagulation and obtain emergent MRI; decompression is time-critical

›Acute traumatic disc extrusion with an unstable spinal injury

›Maintain spinal precautions and manual in-line stabilisation until imaging clears the level

02History/hx41

Pain and radicular features

›Axial versus radicular pain

›Radicular pain radiating below the knee in the leg, or below the elbow in the arm, in a dermatomal band

›Sharp, electric or burning quality with paraesthesiae favours nerve root involvement over mechanical back pain

›Onset and provocation

›Sudden onset with lifting, bending or twisting, often on a background of recurrent axial back pain

›Worse with sitting, forward flexion, Valsalva, coughing and sneezing from raised intradiscal and intrathecal pressure

›Lumbar radicular pain often eased by standing or lying; cervical radicular pain often eased by resting the hand on the head

›Distribution clues to level

›L5 root: buttock, lateral thigh and calf, dorsum of the foot and great toe

›S1 root: posterior thigh and calf, lateral foot and sole, heel

›L4 root: anterior thigh, medial knee and medial calf

›C6 root: lateral forearm, thumb and index finger

›C7 root: posterior arm and middle finger

›Duration and trajectory

›Most radiculopathy improves substantially within 6 to 12 weeks; record whether pain is improving, plateaued or progressing

Red flag symptoms

›Cauda equina symptoms

›Hesitancy, altered urinary sensation, straining, a sense of incomplete emptying, then painless retention with overflow

›Faecal incontinence or loss of the urge to defaecate

›Numbness of the perineum, genitalia, buttocks or inner thighs, including reduced sensation when wiping

›Loss of erection, ejaculation or genital sensation

›Infection and malignancy

›Fever, rigors, night sweats, recent bacteraemia, endocarditis, injection drug use, indwelling lines, recent spinal or epidural procedure

›Known cancer, unexplained weight loss, pain worse at night or at rest, new pain after age 50

›Structural and vascular

›Significant trauma, or minor trauma with osteoporosis or chronic corticosteroid use

›Anticoagulant or antiplatelet therapy or a known bleeding disorder, raising the risk of epidural haematoma

03Physical Exam/exam40

General appearance, vital signs and gait

›Vital signs

›Temperature above 38 degrees Celsius raises concern for epidural abscess, discitis or vertebral osteomyelitis

›Hypertension and tachycardia are common from pain; hypotension with bradycardia suggests cord-level injury

›Posture and movement

›Antalgic list away from the side of a lumbar herniation; splinting, guarded flexion, reluctance to sit

›Cervical herniation held in slight flexion and rotation away from the painful side

›Gait

›Foot-drop steppage gait with L5 involvement; inability to heel-walk (L4 to L5) or toe-walk (S1)

›Wide-based unsteady or spastic gait and a positive Romberg suggest myelopathy rather than isolated radiculopathy

›Spinal palpation

›Focal spinous or interspinous tenderness; paraspinal spasm; a palpable step suggests spondylolisthesis

›Percussion tenderness over a vertebral body is more suggestive of infection or fracture than of disc disease

Motor, reflex and sensory testing by root level

›Lumbosacral motor testing graded 0 to 5

›L2 to L3 hip flexion; L3 to L4 knee extension

›L4 ankle dorsiflexion; L5 great-toe extension and hip abduction; S1 ankle plantarflexion and hip extension

›Test plantarflexion with repeated single-leg heel raises, as bed testing misses mild S1 weakness

›Cervical motor testing

›C5 shoulder abduction and elbow flexion; C6 wrist extension; C7 elbow extension and wrist flexion; C8 finger flexion; T1 finger abduction

›Reflexes

›Depressed knee jerk with L3 to L4; depressed ankle jerk with S1; L5 has no reliable reflex

›Depressed biceps or brachioradialis reflex with C6; depressed triceps reflex with C7

›Hyperreflexia, clonus, a Babinski sign or a Hoffmann sign indicate an upper motor neuron lesion and possible cord compression

›Sensory testing

›Map light touch and pinprick to a dermatome; compare left with right and record a sensory level if present

›Saddle testing of S2 to S4: perianal, perineal and posterior thigh light touch and pinprick

04Differential Diagnosis/ddx34

Cannot-miss spinal emergencies

›Cauda equina syndrome

›Bilateral sciatica, saddle anaesthesia, retention, reduced anal tone; most often a central L4 to L5 or L5 to S1 herniation

›Spinal cord compression with myelopathy

›Cervical or thoracic herniation, or metastatic epidural disease; long-tract signs and a sensory level

›Spinal epidural abscess

›Injection drug use, diabetes, immunosuppression, recent instrumentation; fever with focal spinal pain and raised C-reactive protein

›Vertebral osteomyelitis and discitis

›Insidious unrelenting back pain, raised inflammatory markers, often no fever early

›Spinal epidural haematoma

›Sudden severe pain with rapidly progressive deficit in an anticoagulated patient or after a neuraxial procedure

›Aortic catastrophe presenting as back pain

›Ruptured or symptomatic abdominal aortic aneurysm, or aortic dissection with interscapular pain and a pulse deficit

Musculoskeletal and degenerative mimics

›Non-specific mechanical low back pain and lumbar strain

›Axial pain without a dermatomal radiation or a neurological deficit

›Lumbar spinal stenosis with neurogenic claudication

›Older patient, bilateral leg pain worse with standing and walking, relieved by sitting and forward flexion

›Facet joint arthropathy and spondylolisthesis

›Pain worse with extension and rotation, eased by flexion; a palpable step

›Sacroiliac joint dysfunction and greater trochanteric pain syndrome

›Pain localised to the buttock or lateral hip, provoked by focal palpation and specific stress maneuvers

›Hip osteoarthritis

›Groin pain, limited internal rotation, a positive FABER test; leg pain rarely extends past the knee

›Piriformis syndrome and deep gluteal syndrome

›Buttock pain with sciatic distribution but no back pain and normal imaging of the spine

Referred, neurological and vascular causes

›Peripheral neuropathies

05Laboratory Tests/lt17

Indications for laboratory testing

›No blood tests are required for suspected uncomplicated disc herniation with a normal neurological examination and no red flags

›Send targeted tests when a red flag is present

›Full blood count for infection or malignancy concern

›C-reactive protein and erythrocyte sedimentation rate for infection concern; C-reactive protein is the more sensitive early marker and a normal value substantially lowers the probability of epidural abscess

›Renal function and electrolytes before starting an NSAID, particularly in older patients or those on an ACE inhibitor or diuretic

›Coagulation profile and INR when anticoagulated or before any planned neuraxial intervention or surgery

›Point-of-care glucose in any patient who is lethargic, has diabetes, or is being considered for systemic corticosteroids

Infection, systemic disease and pre-procedure workup

›Infection workup

›Two sets of blood cultures before antibiotics when epidural abscess, discitis or osteomyelitis is suspected

›HIV testing and blood-borne virus screen in people who inject drugs

›Urinalysis and culture, recognising that retention from cauda equina can be misread as a urinary tract infection and delay diagnosis

›Malignancy workup when indicated

›Prostate-specific antigen, serum and urine protein electrophoresis, calcium, alkaline phosphatase when metastatic disease or myeloma is suspected

›Rhabdomyolysis

›Creatine kinase if there has been prolonged immobilisation or a compressive lie

›Pregnancy

›Serum or urine beta-hCG in any person of childbearing potential before imaging or drug selection

06Diagnostic Tests/dt48

Scoring Systems

›Risk stratification tools for back pain trajectory

›STarT Back Screening Tool stratifies low, medium and high risk of persistent disabling pain and directs the intensity of follow-up

›Oswestry Disability Index and Roland-Morris Disability Questionnaire quantify functional limitation for follow-up rather than for ED decisions

›Clinical rules and their limits

›There is no validated decision rule that reliably predicts cauda equina syndrome; a post-void residual below 200 ml has a high negative predictive value but does not exclude an evolving incomplete syndrome

›Straight leg raise, crossed straight leg raise and dermatomal motor, sensory and reflex findings together localise the level and support the need for MRI

›Cord compression grading

›The Bilsky epidural spinal cord compression scale grades metastatic epidural disease on MRI and guides urgency of radiation or surgery

MRI

›Primary test for disc herniation and nerve root or cord compression

›Non-contrast MRI of the symptomatic region visualises protrusion, extrusion and sequestration, the compressed root, and any cord signal change

›Correlate images with the clinical level, because disc herniation is present on MRI in 20 to 30 percent of asymptomatic adults and this fraction rises with age

›Emergent, same-visit MRI indications

›Suspected cauda equina syndrome; image the whole lumbosacral spine

›Suspected cord compression, myelopathy or a sensory level; image the cervical and thoracic spine

›Suspected epidural abscess, discitis or osteomyelitis; add gadolinium contrast

›Suspected epidural haematoma with a progressive deficit

›Add gadolinium contrast for

›Suspected infection or tumour

›Prior lumbar surgery, to distinguish recurrent disc from post-operative scar

›Contraindications and cautions

›Non-conditional pacemaker or implantable defibrillator, certain neurostimulators, cochlear implants, intraocular or intracranial ferromagnetic material

›Use CT myelography when MRI is contraindicated but definitive imaging is required

›In pregnancy, MRI without gadolinium is acceptable at any gestation; avoid gadolinium unless it is essential

›Role

›Second-line when MRI is unavailable or contraindicated; shows calcified disc, bony canal and foraminal stenosis, and fracture better than soft-tissue herniation

›CT myelography approaches MRI accuracy for nerve root compression and is the preferred alternative before urgent surgery when MRI cannot be done

›Trauma

›CT is the first-line study for suspected fracture or instability and for clearing the cervical spine in higher-risk trauma

›Other CT uses

›CT abdomen and pelvis with contrast if a ruptured abdominal aortic aneurysm or another intra-abdominal cause of referred pain is suspected

›Radiation stewardship

›Avoid routine CT of the lumbar spine for atraumatic radicular pain; the gonadal and marrow dose is substantial and it rarely changes management

Ultrasound

›Bladder ultrasound

›Bedside post-void residual measurement is the main point-of-care ultrasound use; serial measurements help track an evolving cauda equina picture

›Confirm a borderline automated bladder-scan volume with an in-and-out catheter before acting on it

›Aorta

›Point-of-care aortic ultrasound to screen for abdominal aortic aneurysm in an older patient with new back pain and cardiovascular risk factors

›Limitations

›Ultrasound cannot image the disc, nerve roots or spinal canal in adults and has no role in diagnosing the herniation itself

›Ultrasound-guided transforaminal or interlaminar injection is an outpatient interventional procedure, not an ED diagnostic test

Plain radiographs and electrodiagnostics

›Plain radiographs

›Do not diagnose disc herniation; use to assess alignment, disc-space height, spondylolisthesis, fracture and destructive lesions

›Weight-bearing flexion and extension views assess dynamic instability when spondylolisthesis is suspected, and are done outpatient once infection and fracture are excluded

›Electromyography and nerve conduction studies

›Not an acute test; findings of denervation take 2 to 4 weeks to appear

›Useful later to confirm the root level, gauge chronicity and severity, and distinguish radiculopathy from a peripheral mononeuropathy or plexopathy

›Bone scan and PET

›Reserved for staging known malignancy or localising occult infection or fracture, arranged by the admitting or outpatient service

07Disposition/dispo27

Emergent surgical and specialty consultation

›Immediate spine surgery referral, same visit

›Confirmed or strongly suspected cauda equina syndrome; the goal is decompression within 24 to 48 hours of onset, and sooner for an incomplete evolving syndrome

›Acute or progressive spinal cord compression with myelopathy

›Rapidly progressive or severe motor deficit, such as a new foot drop with a Medical Research Council grade of 3 or less

›Multidisciplinary emergent pathways

›Spinal epidural abscess: spine surgery plus infectious diseases; most need operative drainage in addition to antibiotics

›Metastatic epidural compression: radiation oncology plus spine surgery, with dexamethasone started in the ED

›Spinal epidural haematoma: spine surgery plus reversal of anticoagulation

›Communication

›Give the consultant the deficit, its onset time and trajectory, the post-void residual, and the imaging level and severity

Admission criteria

›Admit for

›Any acute neurological deficit awaiting inpatient MRI or surgery

›Pain that is uncontrolled despite an adequate multimodal ED regimen, or that prevents mobilising and voiding

›Suspected or confirmed spinal infection, malignancy or fracture

›Inability to void, or a rising post-void residual on serial checks

›Observation and shared care

›Older or frail patients who cannot safely mobilise at home even with a normal examination

›Arrange early physiotherapy and occupational therapy review during any admission

Discharge criteria and transfer

›Safe for discharge when all are met

›No red flags and a non-progressive, non-severe deficit, or a stable long-standing deficit

›Able to walk, transfer and void independently, with a documented normal or baseline post-void residual

›Pain controlled on oral medication, with a written multimodal plan and a named analgesic ceiling

›Understands the cauda equina and infection warning signs and can return quickly

›Outpatient follow-up and, if indicated, MRI are arranged

›Transfer to a spine centre when

08Treatment/t146

Cauda equina and acute cord compression management

›Cauda equina syndrome from disc herniation

›Emergent MRI and emergent spine surgery referral for decompression; surgery within 24 to 48 hours of onset gives the best chance of bladder and ambulatory recovery

›Indwelling urinary catheter for retention, with documented residual volume

›Systemic corticosteroids are not indicated for disc-related cauda equina syndrome; there is no evidence of benefit and they add infection and glycaemic risk

›Keep the patient fasted and maintenance intravenous fluid only, so theatre is not delayed; avoid a large fluid load that itself precipitates or worsens retention

›Metastatic epidural spinal cord compression, if that is the cause rather than disc

›Dexamethasone 10 mg intravenously once as a loading dose, then 4 mg intravenously or orally every 6 hours

›Begin tapering over 1 to 2 weeks once definitive radiation or surgery is under way

›Maximum 16 mg per day outside specialist escalation

›Co-prescribe a proton pump inhibitor and monitor capillary glucose every 6 hours

›Urgent radiation oncology and spine surgery review; surgery before radiation improves ambulation in selected patients with a single area of compression

›Spinal epidural abscess, empirical antibiotics after two sets of blood cultures

›Vancomycin 15 to 20 mg/kg intravenously every 8 to 12 hours

›Target an area-under-curve-guided or trough level per local policy

›Reduce the frequency in renal impairment and monitor levels and creatinine

›Plus ceftriaxone 2 g intravenously every 24 hours

›Substitute cefepime 2 g intravenously every 8 hours or meropenem 2 g intravenously every 8 hours if pseudomonal cover is needed, such as after instrumentation or in injection drug use

›Verify against current pediatric guideline before use in a child or adolescent

›Emergent spine surgery referral for decompression and drainage; antibiotics alone are reserved for patients without a deficit or those who are non-operative

›Serial neurological and bladder checks every 2 to 4 hours for any patient held for an evolving syndrome

First-line analgesia

›Non-steroidal anti-inflammatory drugs, if not contraindicated

›Ibuprofen

›Ibuprofen 400 mg orally every 6 to 8 hours

›Increase to 600 mg every 6 hours if tolerated and response is inadequate

›Maximum 2400 mg per day; take with food; use the shortest effective course

›Naproxen

›Naproxen 500 mg orally twice daily

›Maximum 1000 mg per day for maintenance; a single 1000 mg loading dose may be used

›Preferred NSAID when cardiovascular risk is the main concern

›Ketorolac for severe pain needing a parenteral drug

›Ketorolac 15 mg intravenously every 6 hours

›Use 30 mg intravenously every 6 hours only in a healthy adult under 65 years and over 50 kg with normal renal function

›Maximum 60 mg per day if aged over 65, under 50 kg or with renal impairment, otherwise 120 mg per day; maximum duration 5 days including any oral NSAID that follows

›NSAID cautions carried with the dose

›Avoid with an estimated GFR below 30 ml/min, decompensated heart failure, active peptic ulcer or GI bleeding, and after 20 weeks of pregnancy

›The combination of an NSAID with an ACE inhibitor or angiotensin receptor blocker plus a diuretic markedly raises the risk of acute kidney injury and hyperkalaemia

›Co-prescribe a proton pump inhibitor if age over 65, prior ulcer, or concurrent antiplatelet or anticoagulant

›Paracetamol

›Paracetamol 1 g orally every 6 hours

›Maximum 4 g per day; reduce to 3 g per day if weight under 50 kg, chronic alcohol use, malnutrition or hepatic impairment

›Evidence from the PACE trial shows paracetamol is no better than placebo for acute low back pain; it is retained as a low-risk adjunct and as the analgesic of choice in pregnancy

›Set the target as function and sleep rather than a pain score of zero, and state the total daily ceiling for every agent on the plan

Adjunctive, second-line and neuropathic analgesia

›Short opioid course, only for severe radicular pain not controlled by scheduled multimodal non-opioids

›Morphine for titration in the department

›Morphine 0.05 to 0.1 mg/kg intravenously, roughly 2 to 4 mg per dose

›Repeat every 10 to 15 minutes to effect

›Reduce the dose by 25 to 50 percent and lengthen the interval if age over 65, frailty or an estimated GFR below 30 ml/min

›Verify against current pediatric guideline before use in a child

›Oxycodone for a limited take-home supply

›Oxycodone 5 mg orally every 6 hours as needed

›Limit to a 3 to 5 day supply with no routine refill

›Co-prescribe a stimulant laxative such as senna 8.6 to 17.2 mg orally at night and advise it be taken from the first opioid dose

›Tramadol as an alternative weak opioid

›Tramadol 50 mg orally every 6 hours as needed

›Increase to 100 mg every 6 hours if needed and tolerated

›Maximum 400 mg per day, and maximum 300 mg per day if aged over 75; avoid with an SSRI, SNRI or a seizure disorder because of serotonin syndrome and seizure risk

›Opioid-specific caution: opioid-induced urinary retention and constipation can mask or mimic cauda equina syndrome, so re-examine perineal sensation and bladder function before attributing new retention to the drug

›Neuropathic agents, recognising limited efficacy for acute sciatica

›Gabapentin 300 mg orally at night

›Titrate by 300 mg every 1 to 3 days toward 300 to 600 mg three times daily

›Slow the titration and use 100 mg steps in older patients and when an estimated GFR is below 60 ml/min

›Maximum 3600 mg per day, reduced in proportion to renal function

›Pregabalin 75 mg orally twice daily

›Titrate to 150 mg twice daily after 1 week if needed

›Maximum 300 mg per day for this indication; reduce with renal impairment

›The PRECISE trial found pregabalin did not reduce sciatica leg pain and increased dizziness and falls, so do not start it routinely

›Combined gabapentinoid and opioid prescribing markedly increases sedation and respiratory depression and should be avoided, especially in older patients

›Amitriptyline as a night-time adjunct for radicular pain with sleep disturbance

›Amitriptyline 10 mg orally at night

›Increase to 25 mg at night after 1 to 2 weeks if tolerated

›Avoid with significant cardiac conduction disease, recent myocardial infarction, urinary retention or narrow-angle glaucoma; anticholinergic load makes it a poor choice in older adults

›Duloxetine is reasonable only for chronic musculoskeletal or neuropathic back pain, not for acute sciatica

›Duloxetine 30 mg orally daily for 1 week, then 60 mg orally daily

›Maximum 60 mg per day for this indication

›Avoid with an estimated GFR below 30 ml/min or significant hepatic impairment; do not combine with tramadol

Muscle relaxants and other symptomatic agents

›Skeletal muscle relaxants, for a short course when painful paraspinal spasm is prominent

›Cyclobenzaprine 5 mg orally three times daily

›Increase to 10 mg three times daily if needed and tolerated

›Maximum 30 mg per day; limit the course to 2 to 3 weeks

›Use 5 mg once daily and avoid in adults over 65 because of anticholinergic effects, sedation, falls and delirium; it is on the Beers list

›Methocarbamol 1500 mg orally four times daily for 48 to 72 hours

›Step down to 750 mg every 4 to 6 hours

›Maximum 6 g per day initially, then 4.5 g per day maintenance

›Preferred relaxant in older adults because it is the least anticholinergic, still at a reduced dose

›Tizanidine 2 mg orally every 6 to 8 hours as needed

›Titrate by 2 to 4 mg increments to effect

›Maximum 36 mg per day and no more than 3 doses in 24 hours

›Check liver enzymes if used beyond a short course; avoid with ciprofloxacin or fluvoxamine and with significant hepatic impairment; causes dose-related hypotension

›Diazepam is not recommended: trials show no benefit over placebo for acute low back pain or sciatica and it adds sedation, falls and dependence

›Diazepam 5 mg orally twice daily for no more than 5 days if a clinician still elects to use it, avoiding co-prescription with an opioid

›Antiemetic cover for opioid-related nausea

›Ondansetron 4 mg orally or intravenously every 8 hours as needed, maximum 16 mg per day; review the ECG for QT prolongation if other QT-prolonging drugs are co-administered

›Laxative cover whenever an opioid is prescribed

›Senna 8.6 to 17.2 mg orally at night plus docusate, or polyethylene glycol 17 g orally daily, titrated to a soft daily stool

Systemic corticosteroids and agents not routinely recommended

›Systemic corticosteroids for radiculopathy

›Not recommended for isolated axial back pain and of marginal value for acute sciatica

›If a trial is chosen for severe MRI-confirmed radiculopathy

›Prednisone 60 mg orally daily for 5 days, then taper over the following 9 days, as used in the Goldberg trial

›That trial showed a modest improvement in function, no significant improvement in pain, and no reduction in the rate of subsequent surgery

›Check capillary glucose in patients with diabetes and counsel on mood change and insomnia

›Epidural corticosteroid injection is an outpatient option for radicular pain persisting beyond 4 to 6 weeks; it gives short-term leg-pain relief without changing long-term function or surgical rates and is not an ED procedure

›Agents and interventions with a dose stated so a clinician who still elects them has the number

›Intravenous or intramuscular methylprednisolone as a single ED "back pain shot", for example methylprednisolone 80 to 160 mg intramuscularly, is not supported by evidence for disc herniation and is discouraged

›Systemic antibiotics such as amoxicillin-clavulanate 875/125 mg orally twice daily have no role unless spinal or another infection is confirmed

›Benzodiazepines beyond the single relaxant context above, and carisoprodol 250 to 350 mg orally four times daily, are discouraged for dependence and sedation risk

›Gabapentinoids and opioids as first-line agents; both are second-line at best for this condition

›Bed rest beyond 24 to 48 hours is harmful and should be advised against explicitly

Non-pharmacologic care, activity and interventional options

›Advice and activity

›Reassure that most disc herniations improve within 6 to 12 weeks and that the herniated fragment often resorbs on repeat imaging

›Encourage staying active and continuing ordinary activities as pain allows; avoid prolonged sitting and heavy lifting in the acute phase

›Superficial heat for the first week gives modest short-term relief

›Physical therapy

›Refer for structured physiotherapy, including a directional-preference or McKenzie-based programme and graded core and hip strengthening, starting within 2 to 4 weeks

›Nerve-gliding and postural work for cervical radiculopathy; a soft collar may be used briefly for comfort but not beyond a few days

›Other conservative measures

›Spinal manipulation has limited evidence for radiculopathy and is contraindicated with any progressive neurological deficit, suspected instability, infection or malignancy

›Traction is not recommended as it does not improve outcomes

›Address smoking, weight, sleep and mood, which modify recovery and chronicity risk

›Interventional and surgical options

›Transforaminal epidural steroid injection for persistent radicular pain after 4 to 6 weeks of conservative care

›Microdiscectomy or open discectomy for radicular pain persisting beyond 6 to 12 weeks despite conservative care, or earlier for a significant or progressive motor deficit

›The SPORT trial and the Leiden sciatica trial show earlier surgery relieves leg pain faster, with outcomes converging with conservative care by 1 to 2 years for non-emergent cases, so the decision is preference-sensitive

›Cauda equina syndrome and a severe or progressive deficit are the exceptions that require urgent surgery regardless of duration

Iatrogenic harms and procedural cautions

›The specific way routine care harms this patient

›Prescribing an opioid and a muscle relaxant and discharging a patient with early cauda equina syndrome, whose new urinary retention is then blamed on the drugs, delaying decompression and causing permanent bladder, bowel and sexual dysfunction

›NSAID-precipitated acute kidney injury in a volume-depleted older patient already on an ACE inhibitor and a diuretic

›Intubation and neuromuscular blockade

›Succinylcholine is safe within the first 48 to 72 hours of an acute deficit, but from roughly 72 hours to 6 months after significant motor denervation it can cause hyperkalaemic cardiac arrest through extrajunctional receptor upregulation; use rocuronium 1.2 mg/kg instead

›Watch the monitor for hyperkalaemia after succinylcholine, or with a stacked NSAID and ACE inhibitor in renal impairment: peaked T waves, a widening QRS, loss of P waves and a sine-wave pattern precede arrest

›Maintain manual in-line stabilisation for any suspected unstable cervical level

›Sedation and analgesia

›Deep sedation and repeated opioid boluses impair the serial neurological examination that detects an evolving syndrome; use the smallest effective dose and document the examination before escalation

›Opioid-induced constipation causes straining that transiently raises intrathecal pressure and worsens radicular pain

›Fluids and oxygen

›There is no therapeutic role for fluid loading; excess intravenous fluid can distend the bladder and confuse the retention assessment

›Oxygen only for measured hypoxaemia; target an SpO2 of 94 to 98 percent, or 88 to 92 percent in chronic hypercapnic respiratory disease

›Vasopressors and mechanical circulatory support

›A mean arterial pressure target of 85 to 90 mmHg with vasopressors applies to acute traumatic spinal cord injury, not to atraumatic disc herniation

›Intra-aortic balloon pump and other mechanical circulatory support have no role in this condition

›Anticoagulation and fibrinolysis

›Anticoagulants and antiplatelets raise the risk of spinal epidural haematoma and must be held and, where possible, reversed before neuraxial injection or surgery, following agent-specific timing

›In an admitted immobile patient, weigh mechanical VTE prophylaxis first and delay pharmacological prophylaxis around the time of spinal surgery

›Systemic fibrinolysis given for a concurrent STEMI or ischaemic stroke can be catastrophic if there is an unrecognised epidural abscess or haematoma; factor undiagnosed spinal pathology into that risk assessment

›Analgesia-specific

›Ketorolac and other NSAIDs share the renal, GI and cardiovascular hazards above and should not be stacked with an oral NSAID

›Tramadol and duloxetine together, or either with an SSRI, risk serotonin syndrome

09Special Populations/sp41

Pregnancy

›Presentation and imaging

›Lumbar disc herniation and, rarely, cauda equina syndrome can occur in pregnancy, especially in the third trimester and peripartum

›MRI without gadolinium is acceptable at any gestation and is the test of choice for a suspected deficit; use left lateral tilt after 20 weeks to avoid aortocaval compression

›Avoid gadolinium unless essential, as it crosses the placenta and has been linked to adverse fetal outcomes; avoid CT and radiographs of the spine unless fracture or another cause makes them necessary

›Analgesia

›Paracetamol 1 g orally every 6 hours, maximum 3 to 4 g per day, is first-line

›Avoid NSAIDs after 20 weeks because of the risk of oligohydramnios and fetal renal impairment, and near term because of premature ductus arteriosus constriction; a short course before 20 weeks may be used if needed

›Short-course opioids can be used for severe pain with counselling on neonatal opioid withdrawal if used near delivery; avoid codeine in breastfeeding

›Avoid diazepam, given the first-trimester cleft association and neonatal sedation and withdrawal; gabapentin and pregabalin only if the benefit clearly outweighs the limited safety data; cyclobenzaprine has limited data and is best avoided

›Definitive care

›Cauda equina syndrome in pregnancy needs the same emergent decompression; involve obstetrics and anaesthesia, and position for surgery with left lateral tilt

›Physiotherapy, a pelvic support belt, side-lying positioning and activity modification are the mainstay for uncomplicated radiculopathy

Geriatric

›Broaden the differential

›Spinal stenosis with neurogenic claudication is more common than an acute soft disc; also consider osteoporotic vertebral fracture, metastasis, epidural abscess and abdominal aortic aneurysm

›A first episode of severe back pain after age 50, or any pain with systemic features, warrants imaging and bloods

›Drug safety

›NSAIDs carry a high risk of GI bleeding, acute kidney injury, fluid retention and heart failure; if used at all, use the lowest dose for the shortest time with a proton pump inhibitor, and avoid with an estimated GFR below 30 ml/min or heart failure

›Reduce the paracetamol ceiling to 3 g per day in low body weight or frailty

›Avoid cyclobenzaprine and other anticholinergic relaxants (Beers criteria); if a relaxant is needed use low-dose methocarbamol briefly

›Start opioids at 25 to 50 percent of the usual dose with a laxative, given fall, delirium and respiratory risk; start gabapentin at 100 mg and titrate slowly with renal dosing

›Assessment nuances

›Obtain a baseline post-void residual, since benign prostatic hyperplasia and diabetic cystopathy commonly raise it independent of any cauda equina process

›Have a low threshold for admission when a patient cannot mobilise or self-care safely at home

Pediatrics

›Epidemiology and differential

›Disc herniation is uncommon before adolescence; when it occurs it is often sport-related or associated with a slipped vertebral apophysis

10Background/b36

Epidemiology

›Burden

›Lifetime prevalence of low back pain is roughly 70 to 85 percent; lifetime prevalence of sciatica is about 10 to 40 percent, with a point prevalence near 5 percent

›The annual incidence of a symptomatic lumbar disc herniation is roughly 1 to 2 percent of adults, with a peak at ages 30 to 50 and about a 2 to 1 male predominance

›Level distribution

›About 90 to 95 percent of lumbar herniations are at L4 to L5 or L5 to S1

›Cervical radiculopathy has an incidence near 0.85 per 1000 person-years, with roughly two thirds at C6 to C7 or C7

›Thoracic disc herniations account for well under 1 percent of all symptomatic disc herniations

›Cauda equina syndrome

›Cauda equina syndrome complicates roughly 0.04 percent of lumbar disc herniations, with a population incidence around 1 to 3 per 100000 per year; disc herniation causes about 45 to 60 percent of cases

›Natural history

›Around 85 to 90 percent of radiculopathies improve without surgery within 6 to 12 weeks, and extruded or sequestrated fragments frequently shrink on repeat MRI

›Disc herniation is seen on MRI in 20 to 30 percent of asymptomatic adults under 60 and in more than half of those over 70

›Symptomatic reherniation after discectomy occurs in roughly 5 to 15 percent

Pathophysiology

›Disc structure and failure

›The nucleus pulposus herniates through a defect in the annulus fibrosus; graded as bulge, protrusion, extrusion and sequestration

›Age-related loss of proteoglycan and water content and endplate change predispose the annulus to fissuring

›Root anatomy and which root is hit

›A posterolateral herniation compresses the traversing root, so an L4 to L5 disc typically affects the L5 root and an L5 to S1 disc the S1 root

›A far-lateral or foraminal herniation compresses the exiting root, so an L4 to L5 far-lateral disc affects the L4 root

›Mechanisms of pain

›Both mechanical compression and chemical radiculitis contribute; nucleus pulposus releases tumour necrosis factor alpha, interleukins, phospholipase A2 and nitric oxide, producing nerve root inflammation, oedema and venous congestion

›Dorsal root ganglion sensitisation sustains neuropathic pain after the mechanical insult eases

›Resorption

›Neovascularisation and macrophage-mediated phagocytosis at the fragment surface drive spontaneous regression, which is greatest for extrusions and sequestrations

›Cauda equina and cord

›The spinal cord ends near L1 to L2; below this a large central herniation compresses the lumbosacral roots circumferentially, producing sacral dysfunction of bladder, bowel, perineal sensation and sexual function

11Patient Discharge Instructions/pdi29

Follow-up and safety-netting arrangements

›Before discharge, confirm and document

›A primary care or spine clinic review within 1 to 2 weeks, sooner if the deficit is stable but not resolving

›Outpatient MRI arranged if symptoms persist beyond 4 to 6 weeks or if any non-progressive deficit is present

›A physiotherapy referral, and a clear written multimodal analgesia plan with each drug, its dose, its schedule and its maximum daily amount

›Give explicit return advice

›The patient can state the cauda equina and infection warning signs and knows to return immediately, not wait for the follow-up appointment

›Confirm transport and a support person, and that opioids, if prescribed, are a 3 to 5 day supply with a laxative

copy discharge instructions

›Your diagnosis

›You have a herniated ("slipped") disc that is pressing on a nerve, which causes pain, numbness or tingling that travels into the arm or leg

›Most people improve a lot within 6 to 12 weeks without surgery, and scans often show the disc bulge shrinking on its own

›Return to the emergency department immediately, or call emergency services, if you develop

›Difficulty passing urine, being unable to feel when your bladder is full, or leaking urine or stool

›Numbness between your legs, around the back passage, or in the buttocks or inner thighs

›New or worsening weakness in a leg or arm, a foot that drags, or new unsteadiness when walking

›Fever above 38 degrees Celsius with worsening back pain, or drenching night sweats

›Numbness or weakness in both legs

›Medicines

›Ibuprofen 400 mg with food every 6 to 8 hours as needed, no more than 2400 mg in 24 hours; do not use it if you have kidney disease, a stomach ulcer, heart failure, or if you are more than 20 weeks pregnant

›Paracetamol 1 g every 6 hours as needed, no more than 4 g (8 tablets of 500 mg) in 24 hours; use no more than 3 g per day if you are over 65, are a light person, or drink alcohol regularly

›Do not take two anti-inflammatory medicines at the same time, and do not add other products that also contain paracetamol

›If you were given a stronger painkiller, use it only for the days written on the label, and take the laxative with it to prevent constipation, because straining makes the pain worse

›Activity

›Keep moving and do your normal daily activities as pain allows; do not stay in bed longer than 1 to 2 days, as bed rest slows recovery

›Avoid heavy lifting, repeated bending and twisting, and long periods of sitting for the next few weeks

›Short use of a heat pack and gentle walking often help; start the exercises your physiotherapist gives you

›Follow-up

12References/r21

Society guidelines and appropriateness criteria

›North American Spine Society

›Clinical Guidelines for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy, North American Spine Society, 2012 update

›Clinical Guidelines for the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders, North American Spine Society, 2010

›American College of Physicians

›Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline, Annals of Internal Medicine, 2017

›National Institute for Health and Care Excellence

›NG59: Low Back Pain and Sciatica in Over 16s: Assessment and Management, 2016, updated 2020

›American College of Radiology

›ACR Appropriateness Criteria: Low Back Pain

›Society of British Neurological Surgeons and British Association of Spine Surgeons

›Standards of Care for Investigation and Management of Cauda Equina Syndrome, 2018

Landmark trials and reviews

›Surgery versus conservative care for lumbar disc herniation

›Weinstein JN et al. Spine Patient Outcomes Research Trial (SPORT), JAMA and Spine, 2006 to 2008: faster relief with surgery, outcomes converging with nonoperative care by 1 to 2 years, interpretation limited by crossover

›Peul WC et al. Leiden-The Hague sciatica trial, New England Journal of Medicine, 2007: early surgery relieved leg pain faster with equal outcomes at 1 year

›Pharmacologic trials

›Mathieson S et al. PRECISE trial, New England Journal of Medicine, 2017: pregabalin did not reduce sciatica leg pain and increased adverse events

›Goldberg H et al. JAMA, 2015: a tapering course of oral prednisone for acute radiculopathy from a herniated lumbar disc modestly improved function, did not improve pain, and did not reduce surgery

›Williams CM et al. PACE trial, Lancet, 2014: paracetamol was no better than placebo for acute low back pain

›Narrative reviews

›Deyo RA, Mirza SK. Herniated Lumbar Intervertebral Disk, New England Journal of Medicine, 2016

›Foster NE et al. Lancet Low Back Pain Series, Lancet, 2018

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.