A herniated disk happens when the soft center of a spinal disk pushes through its outer ring and presses on a nerve root, most often in the lower back. Most cases improve within 6 weeks without surgery.
Key symptoms
- Low back pain with pain shooting down one leg (sciatica)
- Numbness or tingling in the leg or foot
- Pain worse with sitting, coughing or bending
- Leg weakness in some patients
What you find on exam
- Straight leg raise brings on leg pain between 30 and 70 degrees
- Dermatome sensation, strength and reflexes (L4 knee, S1 ankle)
- Heel and toe walking
- Saddle sensation and rectal tone when red flags are present
Tests
- No imaging in the first 6 weeks without red flags
- MRI if red flags are present or symptoms last more than 6 weeks
- Nerve conduction studies if the diagnosis is unclear
Treatment basics
- Stay active; avoid bed rest
- NSAIDs, heat and physical therapy
- Epidural steroid injection for persistent leg pain
- Surgery (discectomy) for severe or progressive weakness or failed conservative care
Red flags
- Saddle numbness, urinary retention or incontinence (cauda equina syndrome)
- Progressive leg weakness or foot drop
- Fever, history of cancer or weight loss
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.