Diagnosis and management of lumbar disk disease

Acute low-back pain is one of the most common problems encountered by primary-care physicians. A few patients have severe neurologic impairment or evidence of cancer or other serious underlying systemic illness. For such patients, a broad differential diagnosis must be considered, and a prompt work-up and specialty consultation may be necessary. For most patients with acute low-back pain, extensive laboratory and imaging tests are unnecessary, and rapid improvement can be expected with only simple treatment measures. Physical therapy is useful in patients with refractory symptoms. Magnetic resonance imaging and other sophisticated spinal imaging should usually be reserved for patients who are being considered for an operation. Surgical referral should be considered for the patient with a documented lumbar disk herniation that correlates precisely with clinical findings. Surgical treatment is usually elective in patients with persistent radicular pain and a mild to moderate neurologic deficit, urgent in patients with severe or progressive monoradiculopathy, and emergent in patients with the cauda equina syndrome. Lumbar diskectomy with magnified vision is the surgical procedure of choice, and success rates of 80 to 90% can be expected in properly selected patients.