● symptoms may start off with back pain, which after days or weeks gradually or sometimes suddenly yields to radicular pain often with reduction of the back pain
● precipitating factors: various factors are often blamed, but are rarely identified with certainty
● pain relief upon flexing the knee and thigh (e.g. lying supine with a pillow under the knees)
● patients generally avoid excessive movements; however, remaining in any one position (sitting, standing, or lying) too long may also exacerbate the pain, sometimes necessitating position changes at intervals that range from every few minutes to 10–20 minutes. This is distinct from constant writhing in pain e.g. with ureteral obstruction
● “cough effect”: ↑ pain with coughing, sneezing, or straining at the stool. Occurred in 87% of patients with HLD in one series
● bladder symptoms: the incidence of voiding dysfunction is 1–18%.
Most common: difficulty voiding, straining, or urinary retention. Reduced bladder sensation may be the earliest finding.
The possible causes of this are sensory loss, or incomplete interruption of the preganglionic parasympathetic fibers. Later it is not unusual to see “irritative” symptoms including urinary urgency, frequency (including nocturia), increased post-void residual. Less common: enuresis, and dribbling incontinence; NB: frank urinary retention may indicate cauda equina syndrome.
Occasionally an HLD may present only with bladder symptoms which may improve after surgery.
Discectomy may improve bladder function, but this cannot be assured
Back pain per se is usually a minor component (only 1% of patients with acute low back pain have sciatica), and when it is the only presenting symptom, other causes should be sought;
Sciatica has such a high sensitivity for disc herniation, that the likelihood of a clinically significant disc herniation in the absence of sciatica is ≈ 1 in 1000. Exceptions include a central disc herniation which may cause symptoms of lumbar stenosis (i.e., neurogenic claudication) or a cauda equina syndrome.
Cauda equina syndrome is possible in massive disc herniation.
Mood and anxiety disorders were more commonly seen in patients with lumbar disc herniation than in those without herniation. No relationship was detected between pain severity and mood or anxiety disorders. However, mood and anxiety disorders were associated with neurological deficits 1).