Decision making in lumbar disc disease.

When a patient presents with an acute pain syndrome suggestive of a herniated lumbar disc, nonoperative treatment is almost always the rule. Urgent surgery is undertaken for intractable pain, significant or progressive neurological deficit, and abnormalities of bowel, bladder, or sexual function. Evaluation of the patient is not needed in typical cases until nonoperative care has failed. The decision to evaluate and treat by intervention is made after a reasonable time, usually a minimum of 1 month and a maximum of 3 for the patient who is not making progress. Slow recoveries can be monitored for even longer if agreeable with the patient. The decision for intervention is almost never warranted in the face of normal imaging studies. Several interventions are possible. Traditional surgery, with or without magnification, is followed by an excellent outcome. Chymopapain injection is a reasonable alternative for those expert in its use. Percutaneous discectomy is a possibility but remains to be proved by acceptable clinical studies. Lumbar disc surgery is highly successful and complications are extremely unusual. They do occur however, and can be extremely serious. Unexpected postoperative complications should be investigated immediately. Recovery from disc surgery usually is uneventful, and no rehabilitation is required. Some patients, particularly those who do heavy work, can be helped by a rehabilitation program that stresses return to normal function. Rarely will a patient develop a serious neurological deficit following surgery. Unexpected serious deficits require urgent reevaluation. Most patients return to work promptly without assistance. For those who cannot, referral to a multidisciplinary rehabilitation program to assist with return to function through general management of comorbidities can be useful. It is a rare patient who is disabled by a back disorder, and the decision that a patient is disabled should be made only after thorough evaluation and adequate rehabilitative therapy.