Acute symptoms are usually associated with a herniated disc. This typically leads to leg radicular pain, which may or may not be associated with lower back pain. It is common for patients to have had a history of lower back pain.

Chronic symptoms are usually from degenerative changes of the lumbar spine eventually leading to spinal nerve root, or cauda equina compression (lumbar spondylosis/stenosis).

Initial Diagnosis

With a herniated disc, there is usually an acute or subacute development of leg radicular pain often associated with lower back pain. The patient frequently links this with an episode of minor trauma. Usually, no imaging studies are necessary unless the above is associated with a neurological deficit or fails to respond to conservative management (see below).

With lumbar spondylosis/stenosis, the symptoms are mild early in the disease course. Lumbar spine x-rays are indicated to exclude problems such as instability or pathological fractures. In more advanced cases, a lumbar MRI is indicated. Symptoms can include leg pain, motor deficit and bladder dysfunction. The hallmark of lumbar stenosis is “neurogenic claudication.” Neurogenic claudication is the worsening of leg pain or weakness with ambulation. The symptoms are always relieved by bending at the waist or sitting. A vascular etiology must also be considered in patients with claudication symptoms.

Management

Initial therapy consists of aggressive use of NSAIDs. Symptoms will improve markedly in 1-2 weeks for the majority of patients. Bedrest, opiate analgesics and muscle relaxants may be beneficial for several days. After the acute period, the major consideration is that the back pain and leg radicular pain is improving. Physical therapy may prove helpful. Most of these patients will become symptom-free within several months.

When symptoms are from lumbar spondylosis/stenosis, the major consideration is that the pain is tolerable, and the back mobility is improving. Physical therapy may be required for several months. As stated above, patients with neurological deficits should undergo a lumbar MRI and neurosurgery evaluation obtained.

Indications for Neurosurgery Referral

Intractable leg radicular pain (i.e. failure to respond or worsening during conservative therapy).

Presence of neurological deficit: motor deficit, bladder dysfunction, and neurogenic claudication.

Diagnostic studies should be obtained for any patients meeting the above criteria and prior to the patient being evaluated in Neurosurgery Clinic. Diagnostic studies should include plain lumbar spine x-rays and a lumbar MRI. EMGs of the legs are helpful for surgical indications.