When to Treat Vs. Refer – Herniated disc with Radiculopathy

Lumbar Disc herniation is a common condition that frequently affects the spine in young and middle age individuals due to trauma or sedentary lifestyle and also usually seen with the older adults due to disc degeneration.

Clinical Presentation:

The patient walks into your clinic, with his hand over his back and/or limping. There are bright chances of him have Disc Prolapse.

The symptoms vary depending on the condition:

1) Back Pain

2) Back pain with radiating pain down the leg

3) Sensory abnormalities in legs, genital, anus and/or perineum (depending on the level of nerve root compression.

4) Motor abnormalities like weakness in the leg

5) Lack of balance.

The pain associated with lumbar radiculopathy occurs due to the combination of nerve root ischemia and inflammation resulting from local pressure and neurochemical inflammatory factors within the disc material.

After initial history taking process and physical examination, all the physiotherapist jumps on to Pain reliving modalities and general Physiotherapy exercises. But

1) Should we start treating the patient or refer them to an expert?

2) What are the Red flags and Yellow Flags?

3) How long should we continue with the treatment before we can refer.

4) Should we only consider Physiotherapy as the treatment option or look into various other conservative options?

A Systematic Review published in 2010 addresses all the above concerns and concludes appropriately.

1) Refer to a Surgeon immediately if you find severe sensory or motor deficits, progressive neurologic deterioration or saddle anesthesia with bladder and bowel. It is a RED FLAG situation

2) Refer to a Surgeon, if your patient has already underwent some kind of treatment with no improvement in symptoms for more than 6 months. It is a YELLOW FLAG situation.

3) Acute Low Back Pain: co-ordinate with a physician for pain killers for 1 week giving a window for you to work on his muscles, recommend rest, educate about modified positons and precautions and continue with physiotherapy exercise.

4) Refer to Physician: If the symptoms does not go down within 3-4 weeks of Physiotherapy sessions, refer to the physician for Epidural steroid injection and resume sessions


Surgery will provide more rapid pain relief, but many patients will gradually get better with continues non-operative management, thus patient education and active participation in decision- making is vital. Talk to your patient about advantages and disadvantages of both surgical and conservation management.


Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: evidence-based practice. Int J Gen Med 2010;3:209–14

Dr. Mansi Parikh

Co-Founder EndoRush App