Patients with pain from disk herniation may experience this suddenly after an inciting event (such as lifting a heavy suitcase) or the onset of pain may be gradual (Fig. 26.2). The pain usually radiates down a leg to the foot or toes. There may be associated numbness and/or paresthesia. Physical examination demonstrating specific nerve root irritation or compression (Table 26.3) as well as a positive straight leg raise or a positive contralateral straight leg raise helps confirm the diagnosis. This can be further substantiated by MRI or CT.
Urgent or emergent surgery is indicated in the presence of cauda equina syndrome (loss of bowel or bladder control) and/or progressive neurologic deficits. Otherwise, patients should be treated conservatively in the initial month following the presentation of pain. Bed rest is not helpful and is generally discouraged. Epidural steroid injections may provide faster onset of pain relief, although relief may not be long lasting. Surgery to remove the disk may provide immediate relief, but long-term advantage of surgery over non-surgical management is not clear. Options to remove the disk range from standard laminectomy and discectomy to microdiscectomy, laser discectomy, and percutaneous discectomy.
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