Clinical guidelines for diagnosis and treatment of lumbar disc herniation
Clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy by NASS
Major Recommendations
What history and physical examination findings are consistent with the diagnosis of lumbar disc herniation with radiculopathy?
Manual muscle testing, sensory testing, supine straight leg raise, Lasegue’s sign and crossed Lasegue’s sign are recommended for use in diagnosing lumbar disc herniation with radiculopathy.
Grade of Recommendation: A
The supine straight leg raise, as compared with the seated straight leg raise, is suggested for use in diagnosing lumbar disc herniation with radiculopathy.
Grade of Recommendation: B
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.
Grade of Recommendation: I (Insufficient Evidence)
What are the most appropriate diagnostic tests (including imaging and electrodiagnostics), and when are these tests indicated in the evaluation and treatment of lumbar disc herniation with radiculopathy?
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 are the next most appropriate tests to confirm the presence of lumbar disc herniation.
Work Group Consensus Statement
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.
Grade of Recommendation: A
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.
Grade of Recommendation: A
Electrodiagnostic studies may have utility in diagnosing nerve root compression though 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
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.
Grade of Recommendation: B
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, though are not specific to the diagnosis of lumbar disc herniation.
Grade of Recommendation: B
Medical/Interventional Treatment
What is the role of pharmacological treatment in the management of lumbar disc herniation with radiculopathy?
Tumor necrosis factor (TNF) alpha inhibitors are not suggested to provide benefit in the treatment of lumbar disc herniation with radiculopathy.
Grade of Recommendation: B
There is insufficient evidence to make a recommendation for or against the use of a single infusion of intravenous (IV) glucocorticosteroids in the treatment of lumbar disc herniation with radiculopathy.
There is insufficient evidence to make a recommendation for or against the use of 5-hydroxytryptamine (5-HT) receptor inhibitors in the treatment of lumbar disc herniation with radiculopathy.
There is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy.
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.
There is insufficient evidence to make a recommendation for or against the use of amitriptyline in the treatment of lumbar disc herniation with radiculopathy.
What is the role of physical therapy/exercise in the treatment of lumbar disc herniation with radiculopathy?
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.
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
What is the role of spinal manipulation in the treatment of lumbar disc herniation with radiculopathy?
Spinal manipulation is an option for symptomatic relief in patients with lumbar disc herniation with radiculopathy.
Grade of Recommendation: C
There is insufficient evidence to make a recommendation for or against the use of spinal manipulation as compared with chemonucleolysis in patients with lumbar disc herniation with radiculopathy.
What is the role of contrast-enhanced, fluoroscopic guidance in the routine performance of epidural steroid injections for the treatment of lumbar disc herniation with radiculopathy?
Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery.
Grade of Recommendation: A
What is the role of epidural steroid injections (ESI) for the treatment of lumbar disc herniation with radiculopathy?
Transforaminal epidural steroid injection is recommended to provide short-term (2–4 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy.
Grade of Recommendation: A
Interlaminar epidural steroid injections may be considered in the treatment of patients with lumbar disc herniation with radiculopathy.
Grade of Recommendation: C
There is insufficient evidence to make a recommendation for or against the 12 month efficacy of transforaminal epidural steroid injection in the treatment of patients with lumbar disc herniations with radiculopathy.
What is the role of interventional spine procedures such as intradiscal electrothermal annuloplasty (IDEA) or intradiscal electrothermal therapy (IDET) and percutaneous discectomy (chemical or mechanical) in the treatment of lumbar disc herniation with radiculopathy?
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.
Endoscopic percutaneous discectomy may be considered for the treatment of lumbar disc herniation with radiculopathy.
Grade of Recommendation: C
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.
Grade of Recommendation: B
Automated percutaneous discectomy may be considered for the treatment of lumbar disc herniation with radiculopathy.
Grade of Recommendation: C
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.
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.
There is insufficient evidence to make a recommendation for or against the use of plasma disc decompression as compared with transforaminal epidural steroid injections in patients with lumbar disc herniation who have previously failed transforaminal epidural steroid injection therapy.
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.
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.
What is the likelihood that a patient with lumbar disc herniation with radiculopathy undergoing medical/interventional treatment would have good/excellent functional outcomes at short (weeks–six months), medium (six months–two years) and long-term (greater than two years)?
Medical/interventional treatment is suggested to improve functional outcomes in the majority of patients with lumbar disc herniation with radiculopathy.
Grade of Recommendation: B
Transforaminal epidural steroid injections are suggested to improve functional outcomes in the majority of patients with lumbar disc herniation with radiculopathy.
Grade of Recommendation: B
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.
Are there prognostic factors (e.g., age, duration or severity of symptoms) that make it more likely that a patient with lumbar disc herniation with radiculopathy will have good/excellent functional outcomes at short (weeks–six months), medium (six months–two years) and long-term (greater than two years) following medical/interventional treatment?
Patient age (under 40 years of age) and a shorter duration of symptoms (less than three months) are associated with better outcomes in patients undergoing percutaneous endoscopic lumbar discectomy.
Level of Evidence: II
It is suggested that the type of lumbar disc herniation does not influence outcomes associated with transforaminal epidural steroid injections in patients with lumbar disc herniation with radiculopathy.
Level of Evidence: II/III
It is suggested that a higher degree of nerve root compression negatively affects outcomes associated with transforaminal epidural steroid injections in patients with lumbar disc herniation with radiculopathy.
Level of Evidence: II/III
There is insufficient evidence to make a recommendation regarding the influence of patient age on outcomes associated with medical/interventional treatment for patients with lumbar disc herniation with radiculopathy.
Surgical Treatment
Are there signs or symptoms associated with lumbar radiculopathy that predict a favorable surgical outcome?
It is suggested that patients be assessed preoperatively for signs of psychological distress, such as somatization and/or depression, prior to surgery for lumbar disc herniation with radiculopathy. Patients with signs of psychological distress have worse outcomes than patients without such signs.
Grade of Recommendation: B
There is insufficient evidence to make a recommendation for or against the duration of symptoms prior to surgery affecting the prognosis for patients with cauda equina syndrome caused by lumbar disc herniation with radiculopathy.
It is suggested that patients be assessed using the preoperative straight leg raising test prior to surgery, as the presence of a positive straight leg raise test correlates with better outcomes from surgery for lumbar disc herniation with radiculopathy.
Grade of Recommendation: B
What is the role of epidural steroid injections or selective nerve root blocks in diagnosis or patient selection for subsequent surgical treatment of a lumbar disc herniation with radiculopathy?
No studies were available to directly address this question.
When is the optimal timing for surgical intervention?
Surgical intervention prior to six months is suggested in patients with symptomatic lumbar disc herniation whose symptoms are severe enough to warrant surgery. Earlier surgery (within six months–one year) is associated with faster recovery and improved long-term outcomes.
Grade of Recommendation: B
There is insufficient evidence to make a recommendation for or against urgent surgery for patients with motor deficits due to lumbar disc herniation with radiculopathy.
Does discectomy (with or without preoperative medical/interventional treatment) result in better outcomes (clinical or radiographic) than medical/interventional treatment for lumbar disc herniation with radiculopathy?
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.
Grade of Recommendation: B
In a select group of patients automated percutaneous lumbar discectomy (APLD) 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
There is 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.
Definitions – Grades of Recommendation and Levels of Evidence [available online]