The authors present a vignette of an adult male presenting with sudden onset of low back and left leg pain. Although the patient reportedly has no significant medical history, the patient is certain he “slipped a disc” and requests an MRI. The question posed is, “What testing and treatment would you recommend?”
Richard Deyo, MD and Sohail Mirza, MD discuss the current research on lumbar herniated discs, including diagnostic pearls along with the most efficacious treatment options and guidelines in a recent issue of The New England Journal of Medicine.
Introduction
Patients presenting with acute lower back and leg pain without severe neurological deficit usually respond to NSAIDs and physical therapy without necessity of an MRI. However, if symptoms persist beyond a 4-6 week period, or neurological deficits worsen, an MRI is appropriate. An epidural steroid injection may be recommended for diagnostic as well as therapeutic benefit. Depending on the results of the patient’s examination, nonoperative treatment outcomes, and MRI confirmation of herniated disc, surgical intervention may be considered. 
Lumbar radiculopathy is considered to be both a biochemical (inflammatory) and mechanical process with both genetic and environmental causes. Herniated discs, although the leading cause of lumbar radiculopathy, are frequently found in asymptomatic patients. According to the authors, “The natural history of herniated lumbar discs is generally favorable, but patients with this condition have a slower recovery than those with nonspecific back pain.” In fact, they added, “MRI shows shrinkage of most herniated discs over time, and up to 76% partially or completely resolve by 1 year.” However, recurrences are common. One study showed a 25% recurrence rate.