Lumbar Disc Herniation—the Significance of Symptom Duration for the Indication for Surgery

Abstract

Background: Lumbar disc surgery is among the more common spinal procedures. In this paper, we report the current treatment recommendations for patients with symptomatic disc herniation.

Methods: This review is based on pertinent publications retrieved by a selective literature search in PubMed using the terms [timing] AND [lumbar disc herniation], supplemented by other relevant articles and guidelines.

Results: Symptoms resolve in 60% to 80% of patients with herniated discs in 6-12 weeks, and in 80% to 90% over the long term (≥ 1 year). According to the guidelines, 6-12 weeks of conservative treatment are recommended in the absence of significant neu - rologic deficits. Early surgery is indicated in case of worsening pain or new onset of neurologic deficits. Lumbar disc herniation associated bladder or bowel dysfunction (cauda equina syndrome) is considered an absolute surgical emergency that requires immediate decompression (within 24 to 48 hours). Patients with severe motor deficits (MRC ≤ 3/5) benefit from early intervention and should be offered surgery within three days, if possible, for the best chance of recovery. The degree of weakness and the duration of symptoms have been identified as risk factors for incomplete recovery. Early surgery can be considered in patients with mild paresis (MRC 4/5) in case of functional impairment (e.g., quadriceps paresis).

Conclusion: Longer symptom duration and lower motor scores are associated with worse outcome and a lower chance of neurologic recovery. The recovery rate for motor deficits ranges from 33% to 75%, depending on the timing and modality of treatment as well as the motor score.

Figure 3

Left: Sagittal T2-weighted magnetic resonance image of the lumbar spine showing disc herniation at L4/5. Right: Axial T2-weighted image showing disc herniation, more pronounced on the left side, with compression of the L5 nerve root.

Figure 1

Motor deficit at last follow-up: Bar chart of the recovery rate as a function of the timing of treatment and the degree of preoperative paresis. Modified from the study by Thomé et al. (13)

Figure 2

Plot from the study by Thomé et al. (13) showing the correlation between strength on initial examination and long-term strength after treatment.