When should surgery be advised for a patient with radicular symptoms due to a herniated disc?
Several guidelines suggest that before surgical intervention, patients should have failed conservative therapy for 6 weeks (physical therapy +/– epidural steroids), or have incapacitating pain or an increasing neurologic deficit. They should also exhibit a positive straight leg-raise and other exam findings that correlate with the same pathology identified on lumbar MRI (or CT myelogram). The medium and long-term efficacy of epidural steroids in this setting has been questioned in several studies. The strongest data for efficacy of epidural steroids is for relief of radicular symptoms (not necessarily spinal pain) and for short-term symptomatic benefit only (2–4 weeks).