Snapshot A 59-year-old woman presents to the emergency room with severe low back pain. She reports pain radiating down her left leg into her left foot. The pain started after lifting multiple heavy boxes at her work as a grocery store clerk. On exam, she is unable to bend over due to pain. A straight leg raise elicits severe radiating pain into her left lower extremity. The patient reports that the pain is worst along the posterior thigh and posterolateral leg into the fourth and fifth toes. Introduction Clinical definition a condition in which the central portion of the intervertebral disc herniates beyond the firm outer ring can lead to spinal inflammation +/- nerve root compression also known as a slipped disc, herniated disc, or herniated nucleus pulposus (HNP) Epidemiology demographics male:female ratio is approximately 2:1 peak incidence in 4th and 5th decades location lumbar >> cervical > thoracic risk factors manual labor heavy lifting competitive sports Pathophysiology normal anatomy intervertebral disc login to view 11 more bullets pathoanatomy torsional strain leads to degeneration and tears in the annulus fibrosis nucleus pulposus is able to protrude through the torn annulus fibrosis leads to release of inflammatory markers and may compress a nearby nerve root login to view 2 more bullets common disc herniations login to view 4 more bullets Associated conditions cauda equina syndrome rare caused by a large disc herniation compressing the nerve roots at the end of the spinal cord radicular pain may occur if descending nerve roots into lower extremity are compressed Prognosis natural history of disease 90% of patients will experience symptom improvement within 3 months with nonoperative management Presentation Lumbar disc herniation symptoms low back pain radicular leg pain login to view 3 more bullets physical exam motor exam login to view 7 more bullets provocative tests login to view 5 more bullets Cervical disc herniation symptoms occipital headache neck pain unilateral arm pain, numbness, weakness, and/or tingling physical exam motor exam login to view 10 more bullets provocative tests login to view 3 more bullets Imaging Radiographs indications radiographs not typically indicated findings often normal may demonstrate loss of disc height or loss of lordosis MRI indications not typically indicated unless operative management is being considered best imaging modality to characterize site and extent of lesion Differential Paraspinal muscle strain distinguishing factors will not present with radicular pain will typically resolve within 6 weeks Spondylolisthesis distinguishing factors radiographs will demonstrate slippage of one vertebrae relative to the inferior vertebrae Treatment Nonoperative rest, physical therapy, and anti-inflammatory medications indications login to view 1 more bullet nerve root corticosteroid injections indications login to view 1 more bullet Operative microdiscectomy indications login to view 2 more bullets Complications Cauda equina syndrome incidence occurs in 1-10% of lumbar disc herniations