A 35-year-old male player presents with an acute onset of low back pain after lifting some luggage. He experienced an acute onset of lumbar-region pain with no significant referral. He describes a history of “sciatica” affecting his right leg three years before. This resolved spontaneously over three months.
On examination there was a loss of the normal lumbar lordosis, marked restriction in lumbar movements and diffuse lumbar tenderness. He had a normal lower limb neurological examination.
MRI images from three years previously (when he had right sided sciatica) show a large right sided paracentral disc extrusion at L4/5. This tracks for a 26mm craniocaudal length along the L4 posterior vertebral body margin. The superior component of this disc prolapse compresses the right L4 nerve root along its descent proximal to its neural foramen, while the inferior component of the prolapse compresses the right L5 nerve root within its lateral recess. The central canal remains patent with no cauda equina compression.
Images from the current presentation show that the disc extrusion has resolved. There is very mild low signal scarring/fibrosis in the anterior epidural space related to this old injury. There is now a moderate loss of disc height and signal at this level with mixed Modic type I and II endplate changes There is a new caudal right paracentral extrusion extending posterior to the L5 level body measuring 8 x 4 x 15 mm (TV x AP x CC).
This player’s back pain resolved with a short period of physiotherapy and the use of some simple analgesics. He was able to return to all normal activities over a period of about four weeks. He was advised to continue with core stability and flexibility exercises.
A number of studies have evaluated the natural history of lumbar disc extrusions. These have shown that even large extrusions, as seen in this player, will spontaneously resolve in the majority of cases. Serial MRI’s have shown that most patients will have a reduction in the size of the herniated disc, with about three quarters having complete resolution. The improvement in the radiological findings is often also associated with improvements in symptoms and function. As a result clinicians should consider whether patients can be managed with supportive treatment, rather than with early surgery.
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