Diagnosis And Treatment Of Lumbar Disc Herniation With Radiculopathy
Publication Date: March 15, 2022
Last Updated: March 14, 2022
Recommendations
Definition and natural history
Localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in pain, weakness, or numbness in a myotomal or dermatomal distribution. (, )
(Work Group Consensus Statement)
317978
In the absence of reliable evidence relating to the natural history of lumbar disc herniation with radiculopathy, it is the work group’s opinion that most patientswill improve independent of treatment. Disc herniations will often shrink/regress over time.Many, but not all, articles have demonstrated a clinical improvement with decreased size of disc herniations.
(Work Group Consensus Statement)
317978
Diagnosis and imaging
Manual muscle testing, sensory testing, supine straight leg raise, Lasegue sign, and crossed Lasegue sign are recommended for use in diagnosing lumbar disc herniation with radiculopathy. (A: Recommended)
317978
The supine straight leg raise, compared with the seated straight leg raise, is suggested for use in diagnosing lumbar disc herniation with radiculopathy.
317978
There is insufficient evidence to make a recommendation for or against the use of the cough impulse test, Bell test, hyperextension test, femoral nerve stretch test, slump test, lumbar range of motion, or absence of reflexes in diagnosing lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is a relative paucity of high-quality studies on advanced imaging in patients with lumbar disc herniation. It is the opinion of the work group that in patients with history and physical examination findings consistent with lumbar disc herniation with radiculopathy, magnetic resonance imaging (MRI) be considered as the most appropriate noninvasive test to confirm the presence of lumbar disc herniation. In patients for whom MRI is either contraindicated or inconclusive, computed tomography (CT) or CT myelography is the next most appropriate tests to confirm the presence of lumbar disc herniation.
(Work Group Consensus Statement)
317978
In patients with history and physical examination findings consistent with lumbar disc herniation with radiculopathy, MRI is recommended as an appropriate noninvasive test to confirm the presence of lumbar disc herniation. (A: Recommended)
317978
In patients with history and physical examination findings consistent with lumbar disc herniation with radiculopathy, CT scan, myelography, and/or CT myelography are recommended as appropriate tests to confirm the presence of lumbar disc herniation. (A: Recommended)
317978
Electrodiagnostic studies may have utility in diagnosing nerve root compression although lack the ability to differentiate between lumbar disc herniation and other causes of nerve root compression. When the diagnosis of lumbar disc herniation with radiculopathy is suspected, it is the work group’s opinion that cross-sectional imaging be considered the diagnostic test of choice and electrodiagnostic studies should only be used to confirm the presence of comorbid conditions.
(Work Group Consensus Statement)
317978
Somatosensory-evoked potentials are suggested as an adjunct to cross-sectional imaging to confirm the presence of nerve root compression but are not specific to the level of nerve root compression or the diagnosis of lumbar disc herniation with radiculopathy.
317978
Electromyography, nerve conduction studies, and F waves are suggested to have limited utility in the diagnosis of lumbar disc herniation with radiculopathy. H reflexes can be helpful in the diagnosis of an S1 radiculopathy, although are not specific to the diagnosis of lumbar disc herniation. (B: Suggested)
317978
There is insufficient evidence to make a recommendation for or against the use of motor-evoked potentials or extensor digitorum brevis reflex in the diagnosis of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of thermal quantitative sensory testing or liquid crystal thermography in the diagnosis of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
Medical/interventional treatment
Tumor necrosis factor alpha inhibitors are not suggested to provide benefit in the treatment of lumbar disc herniation with radiculopathy. (B: Suggested, )
317978
There is insufficient evidence to make a recommendation for or against the use of a single infusion of IV glucocorticosteroids in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of 5-hydroxytryptamine receptor inhibitors in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of agmatine sulfate in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of amitriptyline in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of physical therapy/structured exercise programs as stand-alone treatments for lumbar disc herniation with radiculopathy. (Insufficient, )
317978
In the absence of reliable evidence, it is the work group’s opinion that a limited course of structured exercise is an option for patients with mild-to-moderate symptoms from lumbar disc herniation with radiculopathy. (, )
(Work Group Consensus Statement)
317978
Spinal manipulation is an option for symptomatic relief in patients with lumbar disc herniation with radiculopathy.
317978
There is insufficient evidence to make a recommendation for or against the use of spinal manipulation compared with chemonucleolysis in patients with lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of traction in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
Contrast-enhanced fluoroscopy is recommended to guide ESIs to improve the accuracy of medication delivery.
317978
Transforaminal ESI is recommended to provide shortterm (2–4 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy.
317978
Interlaminar ESIs may be considered in the treatment of patients with lumbar disc herniation with radiculopathy. (C: Optional)
317978
There is insufficient evidence to make a recommendation for or against the 12-month efficacy of transforaminal ESI in the treatment of patients with lumbar disc herniations with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the effectiveness of one injection approach over another in the delivery of epidural steroids for patients with lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of intradiscal ozone in the treatment of patients with lumbar disc herniation with radiculopathy. (Insufficient, )
317978
Endoscopic percutaneous discectomy may be considered for the treatment of lumbar disc herniation with radiculopathy. (C: Optional)
317978
Endoscopic percutaneous discectomy is suggested for carefully selected patients to reduce early postoperative disability and reduce opioid use compared with open discectomy in the treatment of patients with lumbar disc herniation with radiculopathy.
317978
Automated percutaneous discectomy may be considered for the treatment of lumbar disc herniation with radiculopathy. (C: Optional)
317978
There is insufficient evidence to make a recommendation for or against the use of automated percutaneous discectomy compared with open discectomy in the treatment of patients with lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of plasma disc decompression/ nucleoplasty in the treatment of patients with lumbar disc herniation with radiculopathy. (Insufficient, )
317978
There is insufficient evidence to make a recommendation for or against the use of plasma disc decompression as compared with transforaminal ESIs in patients with lumbar disc herniation who have previously failed transforaminal ESI therapy. (Insufficient)
317978
There is insufficient evidence to make a recommendation for or against the use of intradiscal high-pressure saline injection in the treatment of patients with lumbar disc herniation with radiculopathy. (Insufficient)
317978
There is insufficient evidence to make a recommendation for or against the use of percutaneous electrothermal disc decompression in the treatment of patients with lumbar disc herniation with radiculopathy. (Insufficient)
317978
There is insufficient evidence to make a recommendation for or against the use of ultrasound or low-power laser in the treatment of lumbar disc herniation with radiculopathy. (Insufficient, )
317978
Medical/interventional treatment is suggested to improve functional outcomes in most patients with lumbar disc herniation with radiculopathy.
317978
Transforaminal ESIs are suggested to improve functional outcomes in most patients with lumbar disc herniation with radiculopathy. (B: Suggested)
317978
There is insufficient evidence to make a recommendation for or against the use of spinal manipulation to improve functional outcomes in patients with lumbar disc herniation with radiculopathy. (Insufficient, )
317978
Patient age (under 40 years of age) and a shorter duration of symptoms (<3 months) are associated with better outcomes in patients undergoing percutaneous endoscopic lumbar discectomy.
317978
It is suggested that the type of lumbar disc herniation does not influence outcomes associated with transforaminal ESIs in patients with lumbar disc herniation with radiculopathy. (, )
(Level of Evidence: II/III)
317978
It is suggested that a higher degree of nerve root compression negatively affects outcomes associated with transforaminal ESIs in patients with lumbar disc herniation with radiculopathy. (, )
(Level of Evidence: II/III)
317978
Surgical treatment
It is suggested that patients be assessed preoperatively for signs of psychological distress, such as somatization and/or depression, before surgery for lumbar disc herniation with radiculopathy. Patients with signs of psychological distress have worse outcomes than patients without such signs. (B: Suggested)
317978
There is an insufficient evidence to make a recommendation for or against the duration of symptoms before surgery affecting the prognosis for patients with cauda equina syndrome caused by lumbar disc herniation with radiculopathy. (Insufficient)
317978
It is suggested that patients be assessed using the preoperative straight leg–raising test before surgery, as the presence of a positive straight leg raise test correlates with better outcomes from surgery for lumbar disc herniation with radiculopathy.
317978
Surgical intervention before 6 months is suggested in patients with symptomatic lumbar disc herniation whose symptoms are severe enough to warrant surgery. Earlier surgery (within 6 months to 1 year) is associated with faster recovery and improved long-term outcomes. (B: Suggested)
317978
There is an insufficient evidence to make a recommendation for or against urgent surgery for patients with motor deficits because of lumbar disc herniation with radiculopathy.
317978
Discectomy is suggested to provide more effective symptom relief than medical/interventional care for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgical intervention. In patients with less severe symptoms, surgery or medical/interventional care appear to be effective for both short- and long-term relief. (B: Suggested, )
317978
In a selected group of patients, automated percutaneous lumbar discectomy may achieve equivalent results to open discectomy; however, this equivalence is not felt to be generalizable to all patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (, )
(Level of Evidence: II/III)
317978
There is an insufficient evidence to make a recommendation for or against the use of spinal manipulation as an alternative to discectomy in patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient, )
317978
There is an insufficient evidence to make a recommendation for or against fusion for specific patient populations with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
When surgery is indicated, performance of sequestrectomy or aggressive discectomy is recommended for decompression in patients with lumbar disc herniation with radiculopathy because there is no difference in rates of reherniation. (B: Suggested)
317978
There is an insufficient evidence to make a recommendation for or against performance of aggressive discectomy or sequestrectomy for the avoidance of chronic low back pain in patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
Use of an operative microscope is suggested to obtain comparable outcomes to open discectomy for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (B: Suggested)
317978
There is an insufficient evidence to make a recommendation for or against the use of medial facetectomy to improve the outcomes for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
There is an insufficient evidence to make a recommendation for or against the specific surgical approach for far lateral disc herniations in patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
There is an insufficient evidence to make a recommendation for or against the use of tubular discectomy compared with open discectomy to improve the outcomes for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery.
317978
There is an insufficient evidence to make a recommendation for or against the application of glucocorticoids, with or without fentanyl, for short-term perioperative pain relief after decompression for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
The application of glucocorticoids, with or without fentanyl, is not suggested to provide long-term relief of symptoms after decompression for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery.
317978
There is an insufficient evidence to make a recommendation for or against the application of a fat graft after open discectomy for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
There is an insufficient evidence to make a recommendation for or against the addition of Oxiplex/SP gel or ADCON- L to discectomy for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. (Insufficient)
317978
The performance of surgical decompression is suggested to provide better medium-term (1–4 years) symptom relief compared with medical/interventional management of patients with radiculopathy from lumbar disc herniation whose symptoms are severe enough to warrant surgery. (B: Suggested)
317978
Surgical decompression provides long-term (>4 years) symptom relief for patients with radiculopathy from lumbar disc herniation whose symptoms warrant surgery. It should be noted that a substantial portion (23%–28%) of patients will have chronic back or leg pain.
(, Level IV)317978
Recommendation Grading
Overview
Title
Diagnosis And Treatment Of Lumbar Disc Herniation With Radiculopathy
Authoring Organization
North American Spine Society
Publication Month/Year
March 15, 2022
Last Updated Month/Year
October 2, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Rehabilitation, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D011843 - Radiculopathy
Keywords
lumbar disc herniation, radiculopathy