|Based on clinical suspicion of a disc herniation, conservative treatment, which may range from simple rest to elaborate traction devices is recommended initially, except when signs of severe or progressive nerve compression (radiculopathy) are present. The individual is instructed to avoid aggravating activities such as heavy lifting, bending, twisting, or prolonged sitting. A corset may be worn during the day to provide support. For relief of pain and inflammation, treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs) and, if pain is severe, a narcotic or an anticonvulsant for its analgesic effects. Muscle relaxants are frequently prescribed for their sedative effects. Other treatments such as ice, heat, massage, and ultrasound therapy may help relieve pain and muscle spasm.|
As symptoms subside, an increase in activity is recommended, including physical therapy and/or a home exercise program to strengthen the lower back and abdominal muscles and improve aerobic capacity (walking). The individual may attend "back school" to learn correct posture and body mechanics. Many individuals recover completely; however, recurrences of back pain and sciatica are common. Therefore, preventive and maintenance measures such as exercise and proper body mechanics may be continued indefinitely.
If little or no improvement is seen after 4 to 6 weeks of treatment, and if the pain is severe and debilitating, further evaluation is appropriate. If imaging studies have not yet been performed, MRI or CT/myelogram are indicated.
Individuals who have leg pain (radicular pain) as the predominant symptom may gain relief through the administration of epidural corticosteroid injections. If non-operative measures are unsuccessful in relieving the individual’s symptoms, surgery consisting of a laminectomy and disc excision or a minimally invasive disc excision, may be considered. Proper patient selection is the key to favorable surgical results, and good outcomes are more highly associated with correlation between clinical findings of radiculopathy and imaging studies. Central disc herniations generally present with low back pain and without radicular complaints; they, rarely benefit from a lumbar laminectomy and discectomy. Individuals who have persistent back pain as the predominant symptom usually do not benefit from surgery intended for disc herniation (discectomy). Individuals with chronic low back pain may benefit from a rehabilitation program, and/or pain management.
Emergent disc excision (discectomy) is indicated in the patient with cauda equina syndrome, which presents with bilateral severe leg pain, saddle anesthesia, and bowel and/or bladder incontinence. Surgery is also indicated in the individual with progressive muscle weakness; severe unilateral leg pain with objective signs of nerve root compression (nerve tension signs and/or loss of neurological function) that has not improved during an adequate trial of conservative treatment, with an imaging study that correlates with the clinical findings for nerve root compression; or recurrent episodes of severe leg pain with objective signs of nerve root compression and a matching defect on imaging studies. Microdiscectomy or minimally invasive discectomy are alternative procedures that may be done on an outpatient basis and may have shorter recovery periods. However, the indications for these procedures are the same as the indications for open laminectomy.
Source: Medical Disability Advisor
|ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*|
|Low Back Disorders|
|* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.|
Source: ACOEM Practice Guidelines