Lumbar Disc Herniation on MRI

Review written by: James Demetrious, DC, DABCO

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The management of lumbar disc herniations requires careful history, examination and assessment. When clinically indicated, MRI evaluation can provide great insight into the severity of disc herniation and other differential possibilities. The prevalence of disc herniation on MRI in the asymptomatic population is quite high. The literature provides ample evidence that disc herniations may retract and recede over time. Chiropractic care can provide relief to many patients with disc herniation.

A Recent Case

A 33-year-old female presents with left S1 dermatomal pain without neurologic deficits of several weeks duration. She describes no recent trauma or injury. Motor, bowel/bladder, and saddle esthesia were preserved. Her primary care physician ordered an MRI of the lumbar spine without contrast.

Axial and sagital T2 weighted images reveal a large left para-sagital L5/S1 extruded disc herniation with caudal extension that is effacing the thecal sac and compromising the exiting nerve root. The right nerve root sleeve is engorged due to effacement of the left S1 nerve sheath (yellow arrow). The L5/S1 IVD is dessicated illustrating the loss of segmental motion and compromised endplate diffusion.










This patient may be a surgical candidate. If neurologic deficits are present, a minimally invasive micro-discectomy utilizing cylinder retractors and endoscopic technique could alleviate the pressure on her nervous system. However, without neurologic deficit, large herniated discs can retract and desiccate overtime. Without neurologic deficits, I may offer a course of chiropractic care with the patient informed consent. With large herniations, I also suggest neurosurgical consultation.

Risk Management and Informed Consent

With suspected and confirmed disc herniations, I regularly discuss with my patients the high prevalence of asymptomatic herniations. I review the possibility of degradation of symptoms and signs that may require medical intervention. I carefully discuss risks and benefits of treatment options and provide the patient the choice of informed consent.

Physicians must carefully and regularly assess patients for burgeoning neurologic deficits that would require surgical intervention. I regularly ask patients with radiculopathy about current bladder, bowel, saddle or sexual dysfunction. I ask them to monitor those issues and seek emergent medical care should they experience signs of cauda equina syndrome.

I take substantial time in reviewing patients’ activities of daily living. I discuss with them at length those activities that may provoke their condition. I strongly advise against any activities that peripheralize symptoms. I make recommendations for alternative means of accomplishing tasks and in many cases, I will recommend cessation of activities and time off from work and leisure pursuits. In doing so, we may provide opportunity to quell localized edema.

In practice, I have found the benefit of ancillary redundancy of care. While I can provide substantial relief to many disc herniation patients, they may benefit from non-steroidal or steroidal medications prescribed by their medical physicians and pain management interventions. For my patients, I discuss the risks and benefits of those procedures as well. Ultimately, I wish to provide them the ability to make decisions that reflect their wishes and needs.

Chiropractic Takeaway…

Chiropractic care can provide substantial relief to this patient population. The literature is quite clear that those patients who seek chiropractic first, experience reduced surgical interventions and opioid dependence. If a patient has recalcitrant symptoms that are unresponsive the chiropractic care, once again, I will make referrals to medical and neurosurgical colleagues.

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