Lumbar Disc Herniation

Conservative Treatment VS Surgery

1. Lumbar Disc Herniation Conservative treatment VS Surgery Ade Wijaya, MD August, 2017

2. Outline Definition Diagnosis Management - conservative vs surgery Conclusion

3. Definition 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. Fardon DF, Milette PC, Combined Task Forces of the North American Spine Society ASoSR, American Society of N. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976). Mar 1 2001;26(5):E93-E113.

4. Diagnosis History and physical examination Manual muscle testing Sensory testing Straight leg test Laseque’s sign Cross Laseque’s sign Confirmation with MRI Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines

5. Management Acute episode of lumbar radiculopathy initially treated with: Pain medication Short course of rest P hysical therapy Epidural steroid injection, if symptoms persist more than 6 weeks or acute severe pain 1.  Bono CM, Wisneski R, Garfin SR. Lumbar disc herniations. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA, editors. The Spine. 5th ed. Philadelphia, PA: Saunders; 2006. 2.  Buttermann GR. Treatment of lumbar disc herniation: Epidural steroid injection compared with discectomy. J Bone Joint Surg Am. 2004;86:670–679. [ PubMed ] 3.  Carragee E. Surgical treatment of disk disorders. JAMA. 2006;296:2485–2487. [ PubMed ]

6. Management Surgical indication: Progressive neurologic deficits Saddle anesthesia Bowel and Bladder dysfunction S ymptoms more than 6 months (even for those who haven’t got conservative treatment) Urgent !

7. Management Medical treatment: - ibuprofen 800 mg every 8 hours as needed - tramadol 50 mg every 4-6 hours as needed More subtanstial pain: hydrocodone-acetaminophen: 5 mg / 500 mg every 4-6 hours as needed Schoenfeld, A. J., & Weiner, B. K. (2010). Treatment of lumbar disc herniation: evidence-based practice.  International journal of general medicine ,  3 , 209.

8. Conclusion Lumbar disc herniation is a common cause of low back pain with radiculopathy Diagnosis made by history and physical examination, confirmed by MRI Management consist of conservative and surgical treatment Conservative treatment including medications, short course of rest, physical therapy, and epidural steroid injection Epidural steroid injection indicated if symptoms persist more than 6 weeks or acute severe pain untreatable with medication alone Surgery is indicated urgently in those who have progressive neurologic deficit, saddle anesthesia, bowel and bladder dysfunction Surgery is also indicated for those who have chronic pain more than 6 months

9. Thank you