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North American
Spine Society
Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care
Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy

Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of
Lumbar Disc
with Radiculopathy
NASS Evidence-Based Clinical Guidelines Committee
D. Scott Kreiner, MD
Committee Chair, Natural History Chair
Steven Hwang, MD
Diagnosis/Imaging Chair
John Easa, MD
Medical/Interventional Treatment Chair
Daniel K .Resnick, MD
Surgical Treatment Chair
Jamie Baisden, MD
Shay Bess, MD
Charles H. Cho, MD, MBA
Michael J. DePalma, MD
Paul Dougherty, II, DC
Robert Fernand, MD
Gary Ghiselli, MD
Amgad S. Hanna, MD
Tim Lamer, MD
Anthony J. Lisi, DC
Daniel J. Mazanec, MD
Richard J. Meagher, MD
Robert C. Nucci, MD
Rakesh D. Patel, MD
Jonathan N. Sembrano, MD
Anil K. Sharma, MD
Jeffrey T. Summers, MD
Christopher K. Taleghani, MD
William L. Tontz, Jr., MD
John F. Toton, MD

Financial Statement
This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating authors have disclosed potential conflicts of interest consistent with NASS' disclosure policy. Disclosures are listed below:
<table><tr><td>D. Scott Kreiner, MD</td><td>Nothing to disclose. (8/14/12)</td></tr><tr><td>Steven Hwang, MD</td><td>Nothing to disclose. (4/22/12)</td></tr><tr><td>John Easa, MD</td><td>Stock Ownership: Janus Biotherapeutics (100000, 3, Janus Biotherapeutics is an auto-immunity company, Paid directly to institution/employer). (11/11/11)</td></tr><tr><td>Daniel K. Resnick, MD</td><td>Board of Directors: Congress of Neurological Surgeons (Nonfinancial); Scientific Advisory Board: Neurosurgical Research Foundation (Nonfinancial); Grants:AANS Spine Section (Level D, research grant through AANS, Paid directly to institution/employer). (2/10/12)</td></tr><tr><td>Jamie Baisden, MD</td><td>Nothing to disclose. (8/14/12)</td></tr><tr><td>Shay Bess, MD</td><td>Royalties: Pioneer (Level B); Consulting:Allosource, DePuy Spine (Level B), Medtronic (Level B); Speaking and/or teaching arrangements: DePuy Spine (Level B);Trips/Travel: DePuy Spine (Level B), Medtronic (Level A); Scientific Advisory Board:Allosource (Level B); Research Support (Investigator Salary): DePuy Spine (Level B); Grants: Orthopedic Research and Education Foundation (Level C). (12/11/11)</td></tr><tr><td>Charles H. Cho, MD, MBA</td><td>Other Office:American Society of Spine Radiology (Nonfinancial, Executive Committee (March 2012 - February 2013). (3/31/12)</td></tr><tr><td>Michael J. DePalma, MD</td><td>Consulting:Vertiflex, Inc (Financial, Hourly consultant, Paid directly to institution/employer); Board of Directors: International Spine Intervention Society (Financial, Only reimbursed for Board related travel., Paid directly to institution/employer),Virginia Spine Research Institute, Inc. (Financial, Salaried position as President; Director of Research, Paid directly to institution/employer); Other Office: Research Committee Vice-Chair, International Spine Intervention Society (Nonfinancial, My registration fee for the 2012 ISIS Annual Scientific Meeting was waived); Research Support (Investigator Salary): Spinal Restoration, Inc. (Level B, Clinical effort covered by this grant as a co-investigator on intradiscal fibrin sealant clinical trial., Paid directly to institution/employer), Mesoblast, Inc. (Level B, Clinical effort covered by this grant as a co-investigator on intradiscal stem cell clinical trial., Paid directly to institution/employer); Grants: Spinal Restoration, Inc. (Level D, Coverage of expenses related to patient enrollment., Paid directly to institution/employer), Mesoblast, Inc. (Level D, Coverage of expenses related to patient enrollment and study start up., Paid directly to institution/employer), St. June Medical (Level C, Coverage of expenses related to retrospective chart review, Paid directly to institution/employer); Relationships Outside the One Year Requirement: AOI Medical (Upcoming Committee Meeting [Clinical Guidelines; Nominating], 03/2010, Consulting, 0), Stryker Interventional Spine (NASS Annual Meeting, 03/2010, Consulting, Level B), St. Jude Medical (NASS Annual Meeting, 03/2010, Consulting), Stryker Biotech (NASS Annual Meeting, 6/2011, Grant, 0), ATRM (NASS Annual Meeting, 6/2011, Grant, 0). (10/1/12)</td></tr><tr><td>Paul Dougherty, II, DC</td><td>Nothing to disclose. (8/24/12)</td></tr><tr><td>Robert Fernand, MD</td><td>Nothing to disclose. (11/15/11)</td></tr><tr><td>Gary Ghiselli, MD</td><td>Royalties: Zimmer Spine (Level D, I am not sure of the exact amount); Stock Ownership: Mesoblast (6500, 0, Pulbically traded company); Private Investments: DiFusion (100000, 9); Consulting: Biomet (Level B for product development and teaching); Scientific Advisory Board: DiFusion (Nonfinancial, Stock options in company). (8/18/11)</td></tr><tr><td>Amgad S. Hanna, MD</td><td>Trips/Travel: Medtronic (Nonfinancial, domestic roundtrip flight, and one hotel night). (4/27/12)</td></tr><tr><td>Tim Lamer, MD</td><td>Nothing to disclose. (5/9/12)</td></tr><tr><td>Anthony J. Lisi, DC</td><td>Nothing to disclose. (8/22/12)</td></tr><tr><td>Daniel J. Mazanec, MD</td><td>Nothing to disclose. (4/20/12)</td></tr><tr><td>Richard J. Meagher, MD</td><td>Nothing to disclose. (8/27/12)</td></tr><tr><td>Robert C. Nucci, MD</td><td>Nothing to disclose. (5/8/12)</td></tr><tr><td>Rakesh D. Patel, MD</td><td>Nothing to disclose. (9/20/11)</td></tr><tr><td>Jonathan N. Sembrano, MD</td><td>Trips/Travel: NuVasive, Inc. (Nonfinancial, Hotel accommodations (2 nights) to attend annual research meeting of SOLAS (Society of Lateral Access Surgeons) in May 2012. (approximately Level A); Scientific Advisory Board: SOLAS (Society of Lateral Access Surgeons) (Nonfinancial); Research Support (Staff/Materials): NuVasive (0, Study site for a multicenter RCT of XLIF vs. MIS TLIF for degenerative spondylolisthesis. Approved January 2010. Four patients enrolled thus far. Approximate value Level B. This would be spent for services of a part-time study coordinator. No investigator remuneration/salary., Paid directly to institution/employer). (8/14/12)</td></tr><tr><td>Anil K. Sharma, MD</td><td>Nothing to disclose. (4/22/12)</td></tr></table>

Jeffrey T. Summers, MD
Private Investments: Morris Innovative (2000, I, The company makes vascular catheters, which are not used for any spine related treatment, or in pain management, and therefore have no potential influence on my practice); Board of Directors: First Choice Insurance (Nonfinancial, I did not accept a further appointment to this board, effective 6/2012), International Spine Intervention Society (ISIS) (Nonfinancial, I am on the ISIS Board of Directors. I also serve as Vice President. Travel expenses (airfare, hotel and parking) are provided when traveling to a Board meeting (official business only). (8/14/12)
Christopher K. Taleghani, MD Royalties: Seaspine (Level C); Speaking and/or teaching arrangements: Medtron (Level B for teaching a course), Globus (Level B for teaching a course). (4/30/12)
William L. Tontz, Jr., MD Stock Ownership: Phygen (1, 6, Physician owned implant company involved in development and distribution of spinal implants., Paid directly to institution/employer); Other Office: Board of Managers (Paid Level B for board of manager term from 2009-2010). (5/9/12)
John F. Toton, MD Nothing to disclose. (4/22/12)
Range Key:
Level A. $100 to $1,000
Level B. $1,001 to $10,000
Level C. $10,001 to $25,000
Level D. $25,001 to $50,000
Level E. $50,001 to $100,000
Level F. $100,001 to $500,000
Level G. $500,001 to $1M
Level H. $1,000,001 to $2.5M
Level I. Greater than $2.5M
Comments
Comments regarding the guideline may be submitted to the North American Spine Society and will be considered in development of future revisions of the work.
North American Spine Society
Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy
Copyright © 2012 North American Spine Society
7075 Veterans Boulevard
Burr Ridge, IL 60527 USA
www.spine.org
ISBN I-929988-32-X

INTRODUCTION/GUIDELINE METHODOLOGY
Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
Table of Contents
I. Introduction....5
II. Guideline Development Methodology 6
III. Natural History of Lumbar Disc Herniation with Radiculopathy....9
IV. Recommendations for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy
A. Diagnosis/Imaging 12
B. Outcome Measures for Treatment 25
C. Medical/Interventional Treatment 26
D. Surgical Treatment 57
E. Value of Spine Care 80
V. Appendices
A. Acronyms....82
B. Levels of Evidence for Primary Research Questions 83
C. Grades of Recommendations for Summaries or Reviews of Studies....84
D. Linking Levels of Evidence to Grades of Recommendation....85
E. NASS Literature Search Protocol....86
VI. References 87
A technical report, including the literature search parameters and evidentiary tables developed by the authors, can be accessed at http://www.spine.org/Documents/LDH_Guideline_Technical_Report.pdf
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
I. Introduction
Objective
The objective of the North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment and functional recovery from this spinal disorder.
Scope, Purpose and Intended User
This document was developed by the North American Spine Society Evidence-based Guideline Development Committee as an educational tool to assist practitioners who treat patients with lumbar disc herniation with radiculopathy. The goal is to provide a tool that assists practitioners in improving the quality and efficiency of care delivered to these patients. The NASS Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy provides a definition and explanation of the natural history, outlines a reasonable evaluation of
patients suspected to have lumbar disc herniation with radiculopathy and outlines treatment options for adult patients with this diagnosis.
THIS GUIDELINE DOES NOT REPRESENT A "STANDARD OF CARE," nor is it intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside this guideline will sometimes be necessary. This guideline should not be seen as prescribing the type, frequency or duration of intervention. Treatment should be based on the individual patient's need and doctor's professional judgment. This document is designed to function as a guideline and should not be used as the sole reason for denial of treatment and services. This guideline is not intended to expand or restrict a health care provider's scope of practice or to supersede applicable ethical standards or provisions of law.
Patient Population
The patient population for this guideline encompasses adults (18 years or older) with a chief complaint of leg pain, numbness or weakness in a dermatomal or myotomal distribution as a result of a primary lumbar disc herniation.
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.
INTRODUCTION/GUIDELINE METHODOLOGY

INTRODUCTION GUIDELINE METHODOLOGY
Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
II. Guideline Development Methodology
Through objective evaluation of the evidence and transparency in the process of making recommendations, it is NASS' goal to develop evidence-based clinical practice guidelines for the diagnosis and treatment of adult patients with various spinal conditions. These guidelines are developed for educational purposes to assist practitioners in their clinical decision-making processes. It is anticipated that where evidence is very strong in support of recommendations, these recommendations will be operationalized into performance measures.
Multidisciplinary Collaboration
With the goal of ensuring the best possible care for adult patients suffering with spinal disorders, NASS is committed to multidisciplinary involvement in the process of guideline and performance measure development. To this end, NASS has ensured that representatives from medical, interventional and surgical spine specialties have participated in the development and review of all NASS guidelines. To ensure broad-based representation, NASS has invited and welcomes input from other societies and specialties
Evidence Analysis Training of All NASS Guideline Developers
NASS has initiated, in conjunction with the University of Alberta's Centre for Health Evidence, an online training program geared toward educating guideline developers about evidence analysis and guideline development. All participants in guideline development for NASS have completed the training prior to participating in the guideline development program at NASS. This training includes a series of readings and exercises, or interactivities, to prepare guideline developers for systematically evaluating literature and developing evidence-based guidelines. The online course takes approximately 15-30 hours to complete and participants have been awarded CME credit upon completion of the course.
Disclosure of Potential Conflicts of Interest
All participants involved in guideline development have disclosed potential conflicts of interest to their colleagues and their potential conflicts have been documented in this guideline. Participants have been asked to update their disclosures regularly throughout the guideline development process.
Levels of Evidence and Grades of Recommendation
NASS has adopted standardized levels of evidence (Appendix A) and grades of recommendation (Appendix B) to assist practitioners in easily understanding the strength of the evidence and recommendations within the guidelines. The levels of evidence range from Level I (high quality randomized controlled trial) to
Level V (expert consensus). Grades of recommendation indicate the strength of the recommendations made in the guideline based on the quality of the literature.
Grades of Recommendation:
A: Good evidence (Level I studies with consistent findings) for or against recommending intervention.
B: Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention.
C: Poor quality evidence (Level IV or V studies) for or against recommending intervention.
I: Insufficient or conflicting evidence not allowing a recommendation for or against intervention.
Levels of evidence have very specific criteria and are assigned to studies prior to developing rec-ommendations. Recommendations are then graded based upon the level of evidence. To better un-derstand how levels of evidence inform the grades of recommendation and the standard nomencla-ture used within the recommendations see Appendix C.
Guideline recommendations are written utilizing a standard language that indicates the strength of the recommendation. "A" recommendations indicate a test or intervention is "recommended"; "B" recommendations "suggest" a test or intervention and "C" recommendations indicate a test or in-tervention "may be considered" or "is an option." "I" or "Insufficient Evidence" statements clearly indicate that "there is insufficient evidence to make a recommendation for or against" a test or in-tervention. Work group consensus statements clearly state that "in the absence of reliable evidence, it is the work group's opinion that" a test or intervention may be appropriate.
The levels of evidence and grades of recommendation implemented in this guideline have also been adopted by the Journal of Bone and Joint Surgery, the American Academy of Orthopaedic Surgeons, Clinical Orthopaedics and Related Research, the journal Spine and the Pediatric Orthopaedic Society of North America.
In evaluating studies as to levels of evidence for this guideline, the study design was interpreted as establishing only a potential level of evidence. As an example, a therapeutic study designed as a randomized controlled trial would be considered a potential Level I study. The study would then be further analyzed as to how well the study design was implemented and significant short comings in the execution of the study would be used to downgrade the levels of evidence for the study's conclusions. In the example cited previously, reasons to downgrade the results of a potential Level I randomized controlled trial to a Level II study would include, among other possibilities: an under-powered study (patient sample too small, variance too high), inadequate randomization or masking of the group assignments and lack of
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
validated outcome measures.
In addition, a number of studies were reviewed several times in answering different questions within this guideline. How a given question was asked might influence how a study was evaluated and interpreted as to its level of evidence in answering that particular question. For example, a randomized control trial reviewed to evaluate the differences between the outcomes of surgically treated versus untreated patients with lumbar spinal stenosis might be a well designed and implemented Level I therapeutic study. This same study, however, might be classified as giving Level II prognostic evidence if the data for the untreated controls were extracted and evaluated prognostically.
Guideline Development Process
Step 1: Identification of Clinical Questions
Trained guideline participants were asked to submit a list of clinical questions that the guideline should address. The lists were compiled into a master list, which was then circulated to each member with a request that they independently rank the questions in order of importance for consideration in the guideline. The most highly ranked questions, as determined by the participants, served to focus the guideline.
Step 2: Identification of Work Groups
Multidisciplinary teams were assigned to work groups and assigned specific clinical questions to address. Because NASS is comprised of surgical, medical and interventional specialists, it is imperative to the guideline development process that a cross-section of NASS membership is represented on each group. This also helps to ensure that the potential for inadvertent biases in evaluating the literature and formulating recommendations is minimized.
Step 3: Identification of Search Terms and Parameters
One of the most crucial elements of evidence analysis to support development of recommendations for appropriate clinical care is the comprehensive literature search. Thorough assessment of the literature is the basis for the review of existing evidence and the formulation of evidence-based recommendations. In order to ensure a thorough literature search, NASS has instituted a Literature Search Protocol (Appendix D) which has been followed to identify literature for evaluation in guideline development. In keeping with the Literature Search Protocol, work group members have identified appropriate search terms and parameters to direct the literature search.
Specific search strategies, including search terms, parameters and databases searched, are documented in the technical report that accompanies this guideline.
Step 4: Completion of the Literature Search
Once each work group identified search terms/parameters, the literature search was implemented by a medical/research librarian, consistent with the Literature Search Protocol.
Following these protocols ensures that NASS recommendations (1) are based on a thorough review of relevant literature;
(2) are truly based on a uniform, comprehensive search strategy; and (3) represent the current best research evidence available. NASS maintains a search history in Endnote, for future use or reference.
Step 5: Review of Search Results/Identification of Literature to Review
Work group members reviewed all abstracts yielded from the literature search and identified the literature they will review in order to address the clinical questions, in accordance with the Literature Search Protocol. Members have identified the best research evidence available to answer the targeted clinical questions. That is, if Level I, II and or III literature is available to answer specific questions, the work group was not required to review Level IV or V studies.
Step 6: Evidence Analysis
Members have independently developed evidentiary tables summarizing study conclusions, identifying strengths and weaknesses and assigning levels of evidence. In order to systematically control for potential biases, at least two work group members have reviewed each article selected and independently assigned levels of evidence to the literature using the NASS levels of evidence. Any discrepancies in scoring have been addressed by two or more reviewers. The consensus level (the level upon which two-thirds of reviewers were in agreement) was then assigned to the article.
As a final step in the evidence analysis process, members have identified and documented gaps in the evidence to educate guideline readers about where evidence is lacking and help guide further needed research by NASS and other societies.
Step 7: Formulation of Evidence-Based Recommendations and Incorporation of Expert Consensus
Work groups held face-to-face meetings to discuss the evidence-based answers to the clinical questions, the grades of recommendations and the incorporation of expert consensus. Expert consensus has been incorporated only where Level I-IV evidence is insufficient and the work group has deemed that a recommendation is warranted. Transparency in the incorporation of consensus is crucial, and all consensus-based recommendations made in this guideline very clearly indicate that Level I-IV evi-dence is insufficient to support a recommendation and that the recommendation is based only on expert consensus.
Consensus Development Process
Voting on guideline recommendations was conducted using a modification of the nominal group technique in which each work group member independently and anonymously ranked a recommendation on a scale ranging from 1 (“extremely inappropriate”) to 9 (“extremely appropriate”). Consensus was obtained when at least 80% of work group members ranked the recommendation as 7, 8 or 9. When the 80% threshold was not attained, up to three rounds of discussion and voting were held to resolve disagreements. If disagreements were not resolved af-
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.
INTRODUCTION/GUIDELINE METHODOLOGY

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
ter these rounds, no recommendation was adopted.
After the recommendations were established, work group members developed the guideline content, addressing the literature which supports the recommendations.
Step 8: Submission of the Draft Guidelines for Review/Comment
Guidelines were submitted to the full Evidence-Based Guideline Development Committee and the Research Council Director for review and comment. Revisions to recommendations were considered for incorporation only when substantiated by a preponderance of appropriate level evidence.
Step 9: Submission for Board Approval
Once any evidence-based revisions were incorporated, the drafts were prepared for NASS Board review and approval. Edits and revisions to recommendations and any other content were considered for incorporation only when substantiated by a preponderance of appropriate level evidence.
Step 10: Submission for Publication and National Guideline Clearinghouse (NGC) Inclusion
Following NASS Board approval, the guidelines have been slated for publication and submitted for inclusion in the National Guidelines Clearinghouse (NGC). No revisions were made at this point in the process, but comments have been and will be saved for the next iteration.
Step 11: Review and Revision Process
The guideline recommendations will be reviewed every three years by an EBM-trained multidisciplinary team and revised as appropriate based on a thorough review and assessment of relevant literature published since the development of this version of the guideline.
Nomenclature for Medical/Interventional Treatment
Throughout the guideline, readers will see that what has traditionally been referred to as “nonoperative,” “nonsurgical” or “conservative” care is now referred to as “medical/interventional care.” The term medical/interventional is meant to encompass pharmacological treatment, physical therapy, exercise therapy, manipulative therapy, modalities, various types of external stimulators and injections.
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
III. Definition and Natural History of Lumbar Disc Herniation with Radiculopathy
What is the best working definition of lumbar disc herniation with radiculopathy?
Localized displacement of disc material beyond the normal margins of the intervertebral disc space \( ^{1} \) resulting in pain, weakness or numbness in a myotomal or dermatomal distribution.
Work Group Consensus Statement
What is the natural history of lumbar disc herniation with radiculopathy?
In order to perform a systematic review of the literature regarding the natural history of patients with lumbar disc herniation with radiculopathy, the above definition of lumbar disc herniation was developed by consensus following a global review of the literature and definitive texts, and used as the standard for comparison of treatment groups. It is important to understand that this is an anatomic definition, which when symptomatic has characteristic clinical features. In order for a study to be considered relevant to the discussion, the patient population was required to be symptomatic, with characteristic clinical features described above, and to have confirmatory imaging demonstrating disc material outside of the normal margins of the intervertebral disc space. The Levels of Evidence for Primary Research Questions grading scale (Appendix B) was used to rate the level of evidence provided by each article with a relevant patient population. The diagnosis of lumbar disc herniation was examined for its utility as a prognostic factor. The central question asked was: “What happens to patients with lumbar disc herniation with radiculopathy who do not receive treatment?”
To address the natural history of lumbar disc herniation with radiculopathy, the work group performed a comprehensive literature search and analysis. The group reviewed 65 articles which were selected from a search of MEDLINE (PubMed), Cochrane Register of Controlled Trials, Web of Science and EMBASE Drugs & Pharmacology for studies published between January 1966 and March 2011.
To meet the work group's definition of “natural history,” literature evaluated could include no treatment with the exception of analgesic medications. All identified studies failed to meet the guideline's inclusion criteria because they did not adequately present data about the natural history of lumbar disc herniation with radiculopathy. These studies did not report results of untreated control patients, thus limiting the validity of the papers' conclusions concerning natural history. This includes works that have been frequently cited as so-called natural history stud-
ies but are, in fact, reports of the results of one or more medical/interventional treatment measures.
Because of the limitations of the available literature, the work group was unable to definitively answer the question posed related to the natural history of lumbar disc herniation with radiculopathy. In lieu of an evidence-based answer, the work group reached consensus on the following statements addressing natural history.
In the absence of reliable evidence relating to the natural history of lumbar disc herniation with radiculopathy, it is the work group's opinion that the majority of patients will improve independent of treatment. Disc herniations will often shrink/regress over time. Many, but not all, papers have demonstrated a clinical improvement with decreased size of disc herniations.
Work Group Consensus Statement
Definition and Natural History References
1. Fardon DF, Milette PC, Combined Task Forces of the North American Spine Society ASoSR, American Society of N. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976). Mar 1 2001;26(5):E93-E113.
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution
NATURAL HISTORY OF LUMBAR DISC
HERNIVATION WITH RADICULOPATHY

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
NATIONAL HISTORY OF LUMBAR DISC
HERNATION WITH RADICULOPATHY
Definition and Natural History Bibliography
1. Abdel-Salam A, Eyres KS, Cleary J. Management of the herniated lumbar disc: the outcome after chemonucleolysis, surgical disc excision and conservative treatments. Eur Spine J. Sep 1992;1(2):89-95.
2. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine (Phila Pa 1976). Aug 1 1996;21(15):1777-1786.
3. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976). Aug 1 1996;21(15):1787-1794; discussion 1794-1785.
4. Atlas SJ, Keller RB, Chang Y, Deyo RA, Singer DE. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine (Phila Pa 1976). May 15 2001;26(10):1179-1187.
5. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). Apr 15 2005;30(8):927-935.
6. Atlas SJ, Tosteson TD, Blood EA, Skinner JS, Pransky GS, Weinstein JN. The impact of workers' compensation on outcomes of surgical and nonoperative therapy for patients with a lumbar disc herniation: SPORT. Spine (Phila Pa 1976). Jan 2010. 1;35(1):89-97.
7. Awad JN, Moskovich R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin Orthop Relat Res. Feb 2006;443:183-197.
8. Benoist M. The natural history of lumbar disc herniation and radiculopathy. Joint Bone Spine. Mar 2002;69(2):155-160.
9. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. Mar 2010. 92(2):147-153.
10. Boskovic K, Todorovic-Tomasevic S, Naumovic N, Grajic M, Knezevic A. The quality of life of lumbar radiculopathy patients under conservative treatment. Vojnosanit Pregl. Oct 2009;66(10):807-812.
11. Bozzao A, Gallucci M, Masciocchi C, Aprile I, Barile A, Passariello R. Lumbar disk herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology. Oct 1992;185(1):135-141.
12. Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976). Oct 1992;17(10):1205-1212.
13. Choi SJ, Song JS, Kim C, et al. The use of magnetic resonance imaging to predict the clinical outcome of non-surgical treatment for lumbar intervertebral disc herniation. Korean J Radiol. Mar-Apr 2007;8(2):156-163.
14. Cowan NC, Bush K, Katz DE, Gishen P. The natural history of sciatica: a prospective radiological study. Clin Radiol. Jul 1992;46(1):7-12.
15. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disc herniation. J Bone Joint Surg Br. Jun 2007;89(6):782-784.
16. Delauche-Cavallier MC, Budet C, Laredo JD, et al. Lumbar disc herniation. Computed tomography scan changes after conservative treatment of nerve root compression. Spine (Phila Pa 1976). Aug 1992;17(8):927-933.
17. Deyo RA. Nonsurgical care of low back pain. Neurosurg Clin N Am. Oct 1991;2(4):851-862.
18. Dullerud R, Nakstad PH. CT changes after conservative treatment for lumbar disk herniation. Acta Radiol. Sep
19. Fahrni WH. Conservative treatment of lumbar disc degeneration: our primary responsibility. Orthop Clin North Am. Jan 1975;6(1):93-103.
20. Fardon DF, Milette PC, Combined Task Forces of the North American Spine Society ASoSR, American Society of N. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976). Mar 1 2001;26(5):E93-E113.
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This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
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This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution
NATURAL HISTORY OF LUMBAR DIASC HERNIAITIN WITH RADICULOPATHY

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
IV. Recommendations for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy
A. Diagnosis and Imaging
Assessing Evidence for Diagnostic Tests
Assessing the evidence for diagnostic tests poses some difficulties that are not seen in therapeutic studies. In the assessment of diagnostic tests, both the accuracy and the effect of testing on the outcome should be considered. The accuracy of a diagnostic test refers to the ability of the examination to detect and characterize pathologic processes. Accuracy is typically expressed in terms of sensitivity and specificity - sensitivity referring to the proportion of patients with the target disorder who will have a positive test, and specificity to the number of people without the disease who have a negative test. \( ^{1} \) With tests that have a high sensitivity, a negative test effectively rules out the disease. With tests that have a high specificity, a positive test effectively rules in the disease.
The performance of a test in a given population can also be stated in terms of positive and negative predictive value, which depends directly on the prevalence of disease in the tested population. \( ^{1} \) In populations with a high prevalence of disease, a test with a high accuracy will accurately predict the presence of disease. Conversely, the same test result will yield a large percentage of false positives in patient populations with a low incidence of disease (such as an asymptomatic population). One of the purposes of a history and physical examination is to increase the prevalence of disease in patients sent for advanced imaging/testing or offered surgery. For this reason, in our systematic review, we have attempted to identify those symptoms or findings which have a high likelihood ratio for lumbar disc herniation with radiculopathy — those symptoms or findings expected in patients diagnosed with lumbar disc herniation with radiculopathy but not in those who do not have the condition. The use of these criteria should increase the prevalence of this disease confirmed by cross-sectional imaging \( ^{1} \) or surgery.
Cross-sectional imaging exams have a low intrinsic specificity as evidenced by a significant incidence of pathologic findings in asymptomatic populations. \( ^{2,3} \) The results of any cross-sectional examination need to be closely correlated with the clinical examination. As a result, the accuracy of a spine MRI or CT should incorporate the ability of the test to directly visualize neurologic structures and the effect of pathologic processes
on these structures. Direct visualization of intrinsic neurologic processes and neural impingement is of obvious importance in determining the etiology of radicular symptoms.
The gold standard in the majority of the studies confirming the presence of a herniated disc was cross-sectional imaging and/or surgery. The gold standard in the diagnosis of lumbar disc herniation is surgery; however, when assessing the validity of subjective complaints or physical examination findings, use of cross-sectional imaging as a gold standard may be considered an acceptable substitute. The validity of surgery as a gold standard can be questioned, however, as findings at surgery can be subjective.
Future Directions for Research
Additional sufficiently-powered observational studies of history/physical examination findings and diagnostic tests are needed to determine their value in influencing treatment assignment and outcome in patients with lumbar disc herniation with radiculopathy.
Assessing Evidence for Diagnostic Tests References
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This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
What history and physical examination findings are consistent with the diagnosis of lumbar disc herniation with radiculopathy?
Manual muscle testing, sensory testing, supine straight leg raise, Lasegue's sign and crossed Lasegue's sign are recommended for use in diagnosing lumbar disc herniation with radiculopathy.
Grade of Recommendation: A
Jensen et al \( ^{1} \) reported a prospective case series calculating the positive predictive value and negative predictive value of sensory and motor abnormalities as signs of the level of a lower lumbar disc herniation. All 52 consecutive patients included in the study had a disc herniation diagnosed by myelogram and confirmed at surgery. Sensory abnormalities were found in 54% of patients with a herniated disc. The positive predictive value (PPV) of sensory disturbances in the L5 dermatome as a sign of a L4-5 disc herniation was 76% and the negative predictive value (NPV) was 55%. The PPV of sensory disturbance in the S1 dermatome as a sign of a L5-S1 disc herniation was 50% and the NPV was 62%. Motor weakness was found in 54% of patients. The PPV of paresis of dorsiflexion of the foot as a sign on herniated disc at L4-5 was 69% and the NPV was 47%. The PPV of paresis of the four lateral toes as a sign of L4-5 herniated disc was calculated to be 76% and the NPV to be 51%. The authors concluded that pin prick sensibility, especially in the foot, and muscular strength of dorsiflexion of the foot and extension of the lateral four toes should be tested in patients with a suspected lumbar nerve compression syndrome. If a lower herniated nucleus pulposus is suspected, hypalgesia in the L5 dermatome and paresis of the above mentioned muscle synergies offer rather specific clues as to the level of the herniation, but these signs are unfortunately not very sensitive. This study provides Level I diagnostic evidence that sensory and motor testing of a patient with a suspected lumbar disc herniation and sciatica can provide specific clues to the level of disc herniation, but are not very sensitive in determining the exact level.
Kortelainen et al \( ^{2} \) described findings from a prospective case series evaluating the reliability of the clinical diagnosis of level of ruptured disc and the utility of lumbar myelography for gaining further information. Of the 403 patients included, all had lumbar disc herniation diagnosed by myelogram and confirmed at surgery. For L5, pain projection was 79% reliable; the reliability rose to 86% with extensor hallucis longus (EHL) weakness. S1 pain was 56% reliable; a dropped Achilles reflex raised reliability to 80%; and the addition of a sensory deficit raised the probability to 86%. Myelography was accurate in 90.8% with a
3.7% false positive rate and a 5.5% false negative rate. The authors concluded that the cough impulse test was positive in 74% of patients with a disc herniation. Lasegue's sign was positive in 94% of patients with a disc herniation. However, these findings are non-specific. A positive straight leg raise occurred less frequently with high level lumbar disc herniations and was more commonly positive under 30 degrees for lower herniations. Projected pain could be localized according to the distribution of the lumbosacral roots in 93% of cases. Pain projection was the most important symptom localizing the level, particularly in the area of the fifth lumbar root. Part of the sensory disturbance, as well as the pain projection, from the L4-5 disc is distributed to the first sacral area. The Achilles reflex was of value in the diagnosis of L5-S1 disc ruptures when associated with pain projection and sensory deficit in the first sacral root. The patellar reflex had no value in the diagnosis of low lumbar lesions. EHL weakness was due to L4-5 rupture in 70% of cases and was a strong sign of L4-5 rupture even if first sacral root projection was present. This study provides Level I diagnostic evidence that physical examination, including subjective and objective findings such as positive straight leg raise, sensory testing and myotomal weakness, in a patient with a suspected lumbar disc herniation and sciatica can provide specific clues to the level of disc herniation.
Poiraudeau et al \( ^{3} \) described a prospective case series including 78 consecutive patients, of which 43 had MRI, CT or myelogram confirmation of lumbar disc herniation, evaluating the reliability, sensitivity, specificity, positive predictive value and negative predictive value for the diagnosis of sciatica associated with disc herniation of the bell test and hyperextension test. Lasegue's sign had the best sensitivity (0.77-0.83), while the crossed leg test had the best specificity (0.74-0.89). Overall, the positive predictive value for all four signs were fair (0.55-0.69) and the negative predictive values were weak to fair (0.45-0.63). The authors concluded that the clinical values of the Bell test and hyperextension test are of interest and at least similar to those of Lasegue's and Crossed Lasegue's signs. The combination of hyperextension with Crossed Lasegue's has excellent specificity and a good positive predictive value for the diagnosis of sciatica associated with disc herniation. Thus, the Bell test and hyperextension test could be performed systematically in standardized physical examination of sciatica. This study provides Level I diagnostic evidence that all four diagnostic tests (hyperextension, Bell, Lasegue's and Crossed Lasegue's) are useful in diagnosing lumbar disc herniation with radiculopathy.
Rabin et al \( ^{4} \) reported a prospective case series of 57 consecutive patients with MRI confirmed lumbar disc herniation, comparing the sensitivity of two methods of performing the straight-
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution
DAGNOSSI/MAGN

Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines
leg raise (SLR) test, one in the supine position and the other in the seated position, in patients presenting with signs and symptoms consistent with lumbar radiculopathy. The sensitivity (95% CI) of the supine SLR test in reproducing the patient's radicular pain in light of an MRI scan indicating the presence of nerve root compression was 0.67 (95% CI, 0.53-0.79). The sensitivity (95% CI) of the seated SLR test was at 0.41 (95% CI, 0.29-0.55). This represented a statistically significant difference with a p value of 0.003. The authors concluded that the traditional SLR test performed in a supine position is more sensitive in reproducing leg pain than the seated SLR test in patients presenting with signs and symptoms consistent with lumbar radiculopathy with MRI evidence of nerve root compression. This study provides Level I diagnostic evidence that the supine SLR is moderately sensitive in diagnosing lumbar disc herniation with radiculopathy. The supine SLR is more sensitive than the seated SLR in diagnosing lumbar disc herniation with radiculopathy.
Vucetic et al \( ^{5} \) reported a prospective case series of 163 consecutive patients with surgically confirmed lumbar disc herniation investigating if the physical signs could predict the degree of lumbar disc herniation. Lumbar range of motion and Crossed Lasegue testing were helpful in predicting 71% of ruptured annulus and 80% of intact annulus. The authors concluded that lumbar range of motion and Crossed Lasegue sign were the only significant physical examination findings, which predict the degree of herniation. This study provides Level I diagnostic evidence that Crossed Lasegue testing and lumbar range of motion in the sagittal plane may be helpful in predicting the type of disc herniation.
The supine straight leg raise, as compared with the seated straight leg raise, is suggested for use in diagnosing lumbar disc herniation with radiculopathy.
Grade of Recommendation: B
Summers et al \( ^{6} \) described a prospective case series of 67 consecutive patients with MRI confirmed lumbar disc herniation testing the construct validity of the Flip Test against the passive supine straight leg raise (SLR) in patients with classic clinical signs of sciatica. The kappa was calculated taking different cut-off points, and maximum agreement occurred at 48°/49° SLR (Kappa 0.771; 95% CI, 0.611 - 0.932). The authors concluded that the Flip Test remains a useful check of nerve root tension but only for patients with supine SLRs below 45°. The most reliable response was not a flip but the demonstration of pain on extension of the knee. The authors recommend the term “sitting SLR test,” as a more accurate and less misleading name. This study provides Level I diagnostic evidence that sitting and supine straight leg raising tests have discrepancy. Flip Test (Sitting SLR) is positive when supine straight leg raising test is positive at less than 45 degrees.
Rabin et al \( ^{4} \) reported a prospective case series of 57 consecutive patients with MRI confirmed lumbar disc herniation, comparing the sensitivity of two methods of performing the straight-leg raise (SLR) test, one in the supine position and the other in the seated position, in patients presenting with signs and symp-
toms consistent with lumbar radiculopathy. The sensitivity (95% CI) of the supine SLR test in reproducing the patient's radicular pa

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