Treatment of Degenerative Disc Disease and Degenerative Spondylolisthesis of the Lumbar Spine - Lumbar Disc Hernations, Primarily Radicular Pain

Intervertebral disc herniation is the most common indication for lumbar surgery. Seventy–five percent of all operations performed on the lumbar spine are for disc herniations. The absolute indications for lumbar disc excisions are cauda equina syndrome or an acute major motor deficit of the lower extremity. The majority of patients with lumbar disc herniations however have pain and/or minor functional impairment as their dominant complaint and so non–operative treatment plays a very dominant role.

Acute Radiculopathy or Sciatica ( < 6 Weeks):

As mentioned previously, disc excision is the treatment of choice emergently if cauda equina syndrome or major motor deficits are present acutely.

The majority of patients with lumbar disc herniations, as previously mentioned, present with radicular pain as their major complaint, which usually responds to non–operative treatment. An exception would be the workers' compensation cohort, which has less favorable results from non–surgical treatment of all types.

Certainly a brief period of bedpost (3–5 days) for patients with severe pain secondary to an acute disc herniation is reasonable to include in the treatment plan. Non–steroidal anti–inflammatory drugs should be started at the time of the initial evaluation. A stretching as well as flexion exercise program should be started when symptoms allow. The use of non–narcotic analgesics should be utilized if no pain response to NSAIDS. A short course of oral steroids also may be helpful at this juncture.

The role of epidural steroids is more controversial with some studies indicating a beneficial effect while others indicate no effect 6,8.

Given the favorable natural history of lumbar disc herniations the majority of patients can resume activities and the pain can be adequately managed with non–operative treatment. In the patient population with the predictably poorest outcomes, i.e., those with psychological problems, workers' compensations and poorly defined physical findings comprehensive rehabilitation programs have success rates exceeding surgical intervention 9.22.

Subacute Radiculopathy or Sciatica (6 Wks – 3 Mos):

If non–operative treatment has not been instituted, institute a treatment program as in acute section. If no response, proceed with further diagnostic studies (MRIs).

Chronic Radiculopathy or Sciatica > 3 Mos:

Proceed with further diagnostic studies (MRI)