Indications for surgery in a patient with symptomatic disc herniation
Overall, approximately 1% of patients with herniated discs eventually require surgery. Absolute indications include disc herniation causing cauda equina syndrome, progressive spinal stenosis, or marked muscular weakness and progressive neurologic deficit despite conservative management. Controversy arises over indications for surgery in patients with less severe symptoms and signs. Relative indications for laminectomy and disc removal include intolerable pain with sciatica symptoms unrelieved by nonsurgical treatment (including corticosteroid injections) and recurrent back pain and sciatica that fail to improve significantly so that a patient can participate in activities of daily living after 6 to 12 weeks of conservative nonsurgical therapy.
Overall, long-term relief of sciatica has been shown to be the same in operative versus nonoperative patients, although the operative patients achieve their degree of relief more rapidly. The best results from surgery are obtained in the emotionally stable patient who has unequivocal disc herniation documented by consistent symptoms, compatible physical examination and tension signs, abnormal EMG that confirms the physical examination, and an abnormal MRI of the spine or myelogram confirming the EMG. The most common cause for surgical failure is poor initial patient selection. Patients should be warned that surgery will help the radicular symptoms but may not help the back pain.