musculoskeletal and connective tissue disorders
Lumbar Herniated Nucleus Pulposus
Treatment of Lumbar Herniated Nucleus Pulposus
Conservative treatment initially Invasive procedures, sometimes including surgery, if neurologic deficits are progressive or severe Because a herniated disk desiccates and shrinks over time, symptoms tend to abate regardless of treatment. Up to 85% of patients with back pain—regardless of cause—recover without surgery within 6 weeks. Treatment of a herniated disk should be conservative unless neurologic deficits are progressive or severe. Heavy or vigorous physical activity is restricted, but ambulation and light activity (eg, lifting objects < 2.5 to 5 kg [about 5 to 10 lb] using correct techniques) are permitted as tolerated; prolonged bed rest and traction are no longer indicated. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or other analgesics should be used as needed to relieve pain. If symptoms are not relieved with nonopioid analgesics, corticosteroids can be given systemically or as an epidural injection; however, analgesia tends to be modest and temporary. Oralmethylprednisolonemay be given, tapered over 6 days, starting with 24 mg daily and decreased by 4 mg a day. In selected patients,gabapentinandamitriptylineare often used for refractory neuropathic pain. Physical therapy and home exercises can improve posture and strengthen back muscles and thus reduce spinal movements that further irritate or compress the nerve root. Invasive procedures should be considered for the following: Persistent or worsening neurologic deficits, particularly objective deficits (eg, weakness, reflex deficits) due to cervical or lumbar radiculopathies Acute Spinal Cord Compression or Severe, intractable nerve root pain or sensory deficits Immediate surgical evaluation is needed if clinical findings of spinal cord compression correlate with MRI abnormalities. Microscopic diskectomy and laminectomy with surgical removal of herniated material are usually the procedures of choice. Percutaneous approaches to remove bulging disk material are still being evaluated. Dissolving herniated disk material with local injections of the enzyme chymopapain is not recommended. Lesions acutely compressing the spinal cord or cauda equina (eg, causing urine retention or incontinence) require immediate surgical evaluation (see Diagnosis ). 