Lumbar Disc Herniation & Sciatica

Symptoms of lumbar disc herniation vary in severity depending on the degree of nerve root compression, the level involved, and individual pain sensitivity. Most patients present with some combination of back pain and radiating leg symptoms. **Common symptoms include:**

• Low back pain — dull aching or sharp, often localized to one side of the lower lumbar region; may be the initial presenting complaint.
• Radiating leg pain (sciatica) — shooting, burning, or electric-shock pain that travels from the buttock down the posterior or lateral thigh, calf, and foot along a specific dermatomal distribution corresponding to the compressed nerve root.
• Numbness and tingling (paresthesia) — abnormal sensations in the affected dermatome, often described as pins-and-needles or a feeling of the leg "falling asleep."
• Muscle weakness — difficulty with specific movements depending on the nerve root involved: foot/ankle dorsiflexion or great toe extension (L5), ankle plantarflexion (S1), or knee extension (L4).
• Pain aggravated by sitting, forward bending (flexion), and Valsalva maneuvers — such as coughing or sneezing, which transiently increase intradiscal pressure and worsen nerve root compression.
• Partial relief with walking or standing in extension — positions that reduce posterior disc pressure and decompress the nerve root.
• Loss or diminution of deep tendon reflexes — reduced or absent patellar reflex (L4), medial hamstring reflex (L5), or Achilles reflex (S1) on the affected side.
• New bladder dysfunction: urinary retention, incontinence, or difficulty initiating urination
• New bowel incontinence or loss of rectal tone
• Saddle anesthesia: numbness in the perineum, inner thighs, and genital region
• Rapidly progressive bilateral leg weakness

> If you are experiencing any of the above red flag symptoms, do not wait for a scheduled appointment. Call Maryland Orthopedic Specialists immediately at [(301) 515-0900](tel:3015150900) or go directly to the nearest emergency department.

A thorough clinical evaluation at MOS combines detailed history-taking with a structured physical examination and selective imaging to confirm the diagnosis, identify the affected nerve root level, and rule out serious pathology.

History & Dermatomal Examination

Our spine specialists take a comprehensive history, including pain character, onset, aggravating/relieving factors, occupation, prior episodes, and screening for red flags. The physical exam maps the distribution of pain, numbness, and weakness to a specific nerve root dermatome and myotome, guiding imaging and treatment decisions.

Straight Leg Raise (SLR) Test

With the patient supine, passive hip flexion with the knee extended places the sciatic nerve under tension. Reproduction of radiating leg pain at 30–70 degrees of elevation constitutes a positive test. This is a sign highly sensitive (~80%) for L4–L5 or L5–S1 disc herniation with nerve root compression. The crossed SLR (contralateral leg elevation reproducing ipsilateral symptoms) has lower sensitivity but higher specificity (~90%) and is particularly suggestive of large central herniations.

Motor, Sensory, and Reflex Testing

Systematic testing localizes the level of involvement:

• L3–L4 (L4 root): Motor — Quadriceps/knee extension weakness; Sensory — Medial calf / inner ankle; Reflex — Patellar (reduced)
• L4–L5 (L5 root): Motor — Ankle/great toe dorsiflexion weakness; Sensory — Lateral calf / dorsum of foot; Reflex — Medial hamstring (variable)
• L5–S1 (S1 root): Motor — Ankle plantarflexion / toe curl weakness; Sensory — Posterior calf / lateral foot / 4th–5th toes; Reflex — Achilles (reduced/absent)

Imaging Studies

• Plain radiographs (X-ray): Obtained to assess overall spinal alignment, disc space height loss, osteophyte formation, and instability. X-rays do not visualize disc herniation directly but help exclude bony pathology and guide further workup.
• MRI (magnetic resonance imaging): The definitive imaging study of choice. MRI provides excellent soft-tissue detail of the intervertebral disc, herniated fragment location (protrusion, extrusion, sequestration), nerve root compression, and adjacent structures. MRI is ordered when symptoms do not resolve with initial conservative treatment within 4–6 weeks, or sooner when red flags or progressive neurological deficits are present.
• EMG / Nerve Conduction Studies (NCS): Performed when the clinical diagnosis is unclear or when peripheral neuropathy, plexopathy, or another neurological etiology must be excluded. EMG/NCS helps confirm nerve root involvement and assess chronicity and severity.

What You Leave With

After your evaluation, you will receive a clear explanation of your diagnosis, the affected nerve root level, and a structured individualized treatment plan. This includes imaging orders, physical therapy referral, and injection scheduling as appropriate.

Natural History Without Surgery

The natural history of lumbar disc herniation is favorable for the majority of patients. Approximately 80–90% of patients experience substantial improvement within 6–12 weeks of symptom onset with appropriate non-operative management. MRI studies demonstrate spontaneous resorption of herniated disc material over time. This process is most robust for sequestered fragments and large extrusions, which undergo an inflammatory-immune-mediated degradation. Saal and Saal (Spine, 1989) demonstrated good-to-excellent outcomes in 90% of conservatively managed patients with radiculopathy at an average follow-up of 31 months.

Recovery After Epidural Steroid Injection

Most patients notice meaningful reduction in radiating leg pain within 3–10 days of a transforaminal ESI. This window of pain relief facilitates active participation in physical therapy, which consolidates the functional recovery. Some patients achieve sufficient relief from 1–2 injections to avoid surgery altogether; others benefit from ESI as a "bridge" while continuing rehabilitation.

Recovery After Microdiscectomy

Microdiscectomy is associated with predictable, relatively rapid recovery for most patients:

• Discharge home — Same day (outpatient) or next day
• Return to light activity / desk work — 2–4 weeks
• Return to moderate physical activity — 4–8 weeks
• Return to full activity / manual labor — 6–12 weeks
• Resolution of radicular leg pain — Often within days to weeks

Postoperative physical therapy is strongly recommended to reduce recurrence risk and restore full functional capacity.

Recurrence Risk

The risk of recurrence of disc herniation at the same or adjacent level after microdiscectomy is approximately 5–15% over 10 years. Risk factors for recurrence include heavy occupational loading, smoking, obesity, and younger age at first herniation. Adherence to a lumbar stabilization exercise program and ergonomic modifications substantially reduces this risk.