DEAR DR. ROACH: I’m a 70-year-old active dentist and pharmacist with chronic lower back pain. My MRI shows a compressed/ extruded disc in contact with a specific nerve. It is extruded by 5 mm. I know that this is very common, and not all patients with compressed nerves are symptomatic. I have specifically located lower back pain and numbness in the muscles of my thigh, which has worsened to weakness.
Two intraspinal injections and daily stretching have helped control the pain, but muscle weakness persists. (I can stand from a squatting position but have difficulty standing from a seated position at times.) I am worried this might interfere with my activities. Am I living with the risk of permanent nerve injury? When should I consider surgery? — F.N.B., DDS ANSWER: You are right that this is a common problem and that most people with a herniated disc will get better with conservative management. Consertative management consists of rest (with exercise only as tolerated), as well as anti-inflammatory and pain medication, followed by physical therapy.
However, when a person develops weakness, it is time to get substantially more concerned. Severe or progressive weakness is one of the clearest indications for neurosurgical intervention, and you should follow up closely with your doctor because of the weakness. It can sometimes be hard to tell weakness that is due to nerve injury apart from weakness that is due to pain, but an experienced examiner is usually able to do so.
Persistent pain in a person with a disc compressing a nerve is an indication for a discussion about surgery with an expert, such as a neurosurgeon or an orthopedic surgeon who frequently perform these surgeries. Overall, people tend to get better with or without surgery, but results are faster with surgery.
There are a few cases where surgery is clearly indicated, but I usually refer my patients when they have severe, persistent pain and severe or progressive weakness, or when a person simply can’t do their daily activities. The decision to have surgery is always up to the patient in consultation with their surgeon, if the surgeon agrees that they are an appropriate surgical candidate.
