The course of a herniated disc with nerve compression is benign. Most patients improve without surgery. Therefore, education, support, and re-evaluation are key elements in the treatment process of these patients.

Re-evaluation is necessary before sending a referral for surgical consideration. If nerve root pain (taugaleiðniverkur) is already decreasing in intensity or distribution at the time of re-evaluation, this usually indicates that further improvement can be expected without intervention.

Indications for surgery

Patients who have:

• Daily, quality-of-life–disturbing radicular pain (taugaleiðniverkur) lasting more than 6–8 weeks

• No improvement despite rest and pharmacological treatment

• Proven nerve root compression on MRI not older than two months

The purpose of surgery is to relieve or cure the radicular pain in the limb.

It should be noted that the time limits for radicular pain duration and surgical indication are relative, individualized, and dependent on symptom development.
Patients who undergo surgery within these timeframes are usually those on full pharmacological treatment, with such severe mobility limitations due to pain that they cannot meet basic daily needs such as toileting, hygiene, or nutrition. Patients with progressive neurological deficits, such as significant paresis in a limb (3/5 muscle strength or less), are operated on earlier.

Cauda equina syndrome symptoms

Patients presenting with signs of cauda equina syndrome should be assessed immediately, and MRI performed the same day.

The symptons of cauda equina includes:

• Urinary retention

• Saddle anesthesia (numbness in the perineal area)

• Reduced anal sphincter tone

• Often bilateral radicular symptoms in the lower limbs

Important

If the patient presents with the above triad of symptoms and MRI shows a herniated disc with cauda equina compression, the on-call neurosurgeon must be contacted immediately. This clinical picture is rare but critical to diagnose and treat urgently with surgery.

Background - Symptoms

In fewer cases, a herniated disc presents with nerve root pain (taugarótarverk), which is a neurogenic pain. This occurs when disc material compresses the nerve root. Symptoms present as radicular pain (taugaleiðniverkur) in the dermatome corresponding to the affected nerve root, in contrast to nociceptive musculoskeletal pain.

Radicular pain is often accompanied by numbness in the corresponding dermatome, and less commonly by motor weakness in the corresponding myotome. The pain is often most severe initially, when inflammation of the nerve is present, and this phase can last about two weeks. During this period, full analgesic treatment is given, and the patient is encouraged to rest in positions that provide relief.

Patients with radicular pain due to disc herniation often also have nociceptive musculoskeletal pain. It is necessary to distinguish between these types of pain and determine which is more disabling for the patient.

Re-evaluation is crucial in the follow-up of patients with radicular pain due to disc herniation. Once radicular symptoms begin to diminish, recovery usually continues without intervention.

Pain medication

Full analgesic treatment typically includes four medication classes: NSAIDs, antiepileptics, opioid-related drugs, and analgesic/antipyretics such as paracetamol.

An example of a full regimen:

• Diclofenac 50 mg x 3

• Gabapentin 600 mg x 3

• Paracetamol + codeine (Parkodin forte) 2 x 4

Occasionally, a short course of corticosteroids is given to reduce severe pain when the diagnosis has been confirmed, to help the patient through the worst pain phase.
Example regimen: Decortin/Prednisolone 5 mg tablets – 50 mg day 1, 40 mg day 2, 30 mg day 3, 20 mg day 4, 10 mg day 5, 5 mg day 6, then stop.

Education and regular follow-up of the patient play a key role in the recovery process.

Supplementary material