Given all the structures in the body why has the lumbar disc continued to create zealots whose obsession with this tissue as the primary source of back and leg pain borders on a perversion? This just published paper in the New England Journal of Medicine by Barzouhi and colleagues entitled MRI in Follow-up Assessment of Sciatica should put to rest any doubts on the predictive ability of lumbar disc “pathology” in providing diagnostic or prognostic ability when it comes to sciatica. This paper evaluated 283 patients randomized into either surgery or prolonged conservative care for sciatica and lumbar-disk herniation and analyzed their MRIs at baseline and after 1 year. This secondary analysis found that an MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disk herniation did not distinguish between those with a favorable outcome and those with an unfavorable outcome. This article is a treasure trove of information. The authors also noted that distinguishing between disc protrusions and extrusions did not have diagnostic value. We have all had patients with postoperative formation of epidural scars which is hypothesized to cause mechanical traction on the dura or nerve roots and thus “causing” the persistent back and leg pain after spinal surgery. However, this study did not find a positive correlation between the presence of scar tissue and symptoms. This has far reaching implications for how we “counsel” and manage this population.
I am not suggesting we make disc pornography illegal, but we should be cautious of how providers and patients interpret it.