Lumbar Disc Herniation, ABOS Oral Boards Preparation

This is a 38-year-old male high school football coach with a six-week history of progressive left lower extremity radiculopathy. He describes sharp, burning pain radiating from his left buttock down the posterolateral thigh and calf to the dorsum of his foot, that distribution is classic L5. The pain is worse with sitting and Valsalva maneuvers. No medical comorbidities.

He initially managed the symptoms with 800mg ibuprofen three times daily and activity modification for two weeks. When that did not resolve his symptoms, he completed four weeks of physical therapy focused on core stabilization and nerve mobilization. He also received an epidural steroid injection at the L4-L5 level three weeks ago, it gave him about ten days of relief and then the pain returned. Importantly, he denies bowel or bladder dysfunction, saddle anesthesia, or bilateral leg symptoms. I specifically asked about these because cauda equina syndrome is the one presentation that changes this from an elective to an emergent situation.

On exam, straight leg raise was positive at 35 degrees on the left, negative on the right. Cross-over straight leg raise was negative. EHL strength was 4 out of 5 on the left, a motor deficit that concerns me. Ankle dorsiflexion was 4+ out of 5. Ankle jerk was diminished on the left. Sensation was diminished over the lateral calf and dorsum of the foot, L5 distribution. Femoral nerve stretch test was negative, ruling out upper lumbar pathology.

MRI showed a large left paracentral disc herniation at L4-L5 with caudal migration, compressing the traversing left L5 nerve root. No central stenosis, no cauda equina compression.

After six total weeks of conservative management with persistent and progressing motor weakness, surgery was indicated. A motor deficit that is not improving despite conservative care is a relative indication for surgical intervention. We discussed the natural history, most herniations resolve, but his was worsening, and he elected for surgery.

I performed a left-sided L4-L5 microdiscectomy through a standard posterior approach. The L5 nerve root was edematous but in continuity. I removed the herniated fragment.

He reported immediate resolution of his leg pain in the recovery room. He was discharged home the same day. At two weeks, he was walking comfortably with no radicular symptoms. At six weeks, EHL strength had improved to 4+ out of 5 and he was back to coaching. At three months, strength was 5 out of 5 and he was functioning well. I counseled him on the risk of recurrent herniation and emphasized core strengthening and proper body mechanics going forward.

He was very satisfied, the leg pain was gone and he was back to coaching without significant restrictions. If I saw this case again, I might have given conservative management a longer trial before operating, particularly since the motor deficit was only 4 out of 5 and not progressing rapidly. The literature supports that many L5 motor deficits recover with time, and a longer observation period with serial exams might have been reasonable. That said, his motor weakness was worsening despite therapy, which justified the timing. I watched for recurrent herniation at follow-up and counseled him on the importance of continued core strengthening.