An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

D. Scott Kreiner, Steven W. Hwang, John E. Easa, Daniel K. Resnick, Jamie L. Baisden, Shay Bess, Charles H. Cho, Michael J. Depalma, Paul Dougherty, Robert Fernand, Gary Ghiselli, Amgad S. Hanna, Tim Lamer, Anthony J. Lisi, Daniel J. Mazanec, Richard J. Meagher, Robert C. Nucci, Rakesh D. Patel, Jonathan N. Sembrano, Anil K. SharmaJeffrey T. Summers, Christopher K. Taleghani, William L. Tontz, John F. Toton

Research output: Contribution to journalReview articlepeer-review

422 Scopus citations


Background context The objective of the North American Spine Society's (NASS) Evidence-Based 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. Purpose To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy. Study design Systematic review and evidence-based clinical guideline. Methods This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline. Results Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Conclusions The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

Original languageEnglish (US)
Pages (from-to)180-191
Number of pages12
JournalSpine Journal
Issue number1
StatePublished - Jan 1 2014

Bibliographical note

Funding Information:
DSK: Nothing to disclose. SWH: Nothing to disclose. JEE: Stock Ownership: Janus Biotherapeutics (E, Paid directly to institution). DKR: Board of Directors: NASS Board of Directors (Research Council Director) (None), Congress of Neurological Surgeons President Elect (None); Scientific Advisory Board/Other Office: Neurosurgical Research Foundation (None); Grants: AANS Spine Section Grant (D, Paid directly to institution/employer). JLB: Support for travel to meetings for the study or other purposes: NASS (A). SB: Royalties: Pioneer (B); Consulting: DePuy Spine (B), Medtronic (B), Lanyx (B), Alphatec (B), Allosource (B); Speaking and/or Teaching Arrangements: Medtronic (B); Scientific Advisory Board/Other Office: Allosource (B); Grants: DePuy Spine (B). CHC: Board of Directors: American Society of Spine Radiology (Executive Committee [March 2012 to February 2013], None). MJD: Consulting: Vertiflex (Financial, Hourly consultant, Paid directly to institution/employer); Board of Directors: ISIS (travel reimbursement, Paid directly to institution/employer), Virginia Spine Research Institute, Inc. (Salaried position as President; Director of Research, Paid directly to institution/employer); Scientific Advisory Board/Other Office: Research Committee Vice-Chair, International Spine Intervention Society (None); Research Support (Investigator Salary): Spinal Restoration, Inc. (B, Paid directly to institution/employer), Mesoblast, Inc. (B, Paid directly to institution/employer); Grants: Spinal Restoration, Inc. (D, Paid directly to institution/employer), Mesoblast, Inc. (D, Paid directly to institution/employer), St. Jude Medical (C, 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, 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). PD: Nothing to disclose. RF: Nothing to disclose. GG: Royalties: Zimmer Spine (D); Stock Ownership: Mesoblast (B); Private Investments: DiFusion (E); Consulting: Biomet (B); Scientific Advisory Board/Other Office: DiFusion (None/Stock options in company). ASH: Trips/Travel: Medtronic (None). TL: Nothing to disclose. AJL: Grants: NCMIC Foundation (F, Paid directly to institution). DJM: Nothing to disclose. RJM: Nothing to disclose. RCN: Nothing to disclose. RDP: Consulting: Globus (B), Stryker (B); Speaking and/or Teaching Arrangements: Globus (B), Stryker (B). JNS: Board of Directors: Society of Lateral Access Surgeons (None), Philippine Minnesota Medical Association (None), University of the Philippines Alumni of Minnesota (None); Research Support (Investigator Salary, Staff/Materials): NuVasive (None, Paid directly to institution/employer). AKS: Nothing to disclose. JTS: Private Investments: Morris Innovative (2000 shares), MediWorkx (15% ownership interest); Board of Directors: First-Choice Insurance (None/Term ended June 2012), International Spine Intervention Society (None, travel reimbursement, Board of Directors and Vice President). CKT: Royalties: Seaspine (D), Globus (<A); Consulting: Seaspine (B), Theken (C); Speaking and/or Teaching Arrangements: Globus (B). WLT: Stock Ownership: Phygen (6%, Paid directly to institution/employer); Board of Directors: Board of Managers 2009–2010 (B). JFT: Nothing to disclose.


  • Guideline
  • Lumbar disc herniation
  • Radiculopathy


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