Management of Patients with Disc Herniation

Initial Management and Surgical Referral

Patients with disc herniation typically present with radicular symptoms consistent with spinal nerve compression and sometimes low back pain, and should initially be referred to a neurologist or interventional physiatrist for conservative management, with surgical referral only when conservative measures fail or specific indications are present 1
Surgery should be considered only when nonoperative treatments fail to provide adequate relief, progressive neurological deficits are present, cauda equina syndrome develops, or severe, disabling pain persists despite conservative management 1
The American College of Neurosurgery recommends that lumbar fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy, and should be considered only in specific circumstances, such as patients with significant chronic axial back pain, manual laborers, patients with severe degenerative changes, or patients with instability associated with radiculopathy 1, 5

Neurosurgical or orthopedic spine surgeon referral is indicated for patients with failed conservative management, recurrent disc herniations, especially with instability or chronic axial low back pain, or manual laborers with significant chronic axial back pain who may benefit from fusion 1, 2, 3
Patients with demonstrated preoperative instability should also be referred to a neurosurgical or orthopedic spine surgeon 2, 4

Manual laborers may benefit from fusion at the time of discectomy, with 89% of fusion patients vs. 53% of discectomy-only patients maintaining work activities at 1 year, although return to work is faster with discectomy alone (12 weeks vs. 25 weeks) 3
Patients with recurrent disc herniations show good outcomes with fusion, with a 92% improvement rate and 90% satisfaction with posterior decompression and fusion 2, 3