Before the article begins, an introduction to the Level of Evidence and Level of Recommendation classifications is in order for your fellow warriors to understand the content of the following guidelines more accurately. The U.S. Preventive Medicine Task Force’s grading methodology can be used to evaluate the quality of evidence for treatment or screening: Level I evidence: evidence derived from at least one well-designed randomized controlled clinical trial; Level II-1 evidence: evidence derived from well-designed nonrandomized controlled trials; Level II-2 evidence: evidence derived from well-designed cohort or case-control studies (preferably multicenter studies); Level II-3 evidence: evidence derived from multiple time-series studies with or without intervention. Results from uncontrolled trials with highly significant differences can sometimes be used as evidence for this level; Level III evidence: authoritative opinion from clinical experience, descriptive studies, or expert committee reports. The U.S. Preventive Medicine Task Force’s Recommendation Evaluation Criteria: Level A Recommendation: Good scientific evidence suggesting that the benefits of the medical practice substantially outweigh its potential risks. The clinician should discuss the medical practice with the applicable patient; Level B recommendation: at least fair evidence suggesting that the benefits of the medical practice outweigh its potential risks. The clinician should discuss the medical practice with the applicable patient; Level C recommendation: at least fair scientific evidence suggests that the medical practice provides benefit, but the benefit is too close to the risk to make a general recommendation. The clinician is not required to offer this medical practice unless certain individualized considerations exist; Level D recommendation: at least fair scientific evidence suggests that the potential risks of the medical practice outweigh the potential benefits; the clinician should not routinely perform the medical practice on asymptomatic patients; Level I recommendation: the medical practice lacks scientific evidence, or the evidence is of low quality or is in conflict with each other, e.g., the risks and benefits are not measurable and cannot be assessed. .. Clinicians should help patients understand the uncertainty surrounding the medical practice. To further improve the diagnosis and treatment of lumbar disc herniated radiculopathy, the Lumbar Disc Herniation Radiculopathy Working Group under the Evidence-Based Medicine Clinical Guidelines Development Committee of the North American Society of Spine Surgeons (NASS) has summarized and synthesized the available clinical medical evidence, which is now translated into the following guideline for the reference of orthopedic surgeons. Definition and Natural History Question 1: What is the most accurate definition of lumbar disc herniated radiculopathy? A condition in which the material of an intervertebral disc is misaligned beyond the limits of the normal disc boundaries and compresses the nerves, resulting in pain, weakness, musculoskeletal paralysis, or abnormal dermatomal sensory distribution. LEVEL OF EVIDENCE: EXPERT CONSENSUS Question 2: What is the natural course of lumbar disc herniated radiculopathy? Because there are no studies related to the natural course of lumbar disc herniated radiculopathy, the Working Group agreed that most patients with lumbar disc herniated radiculopathy improve with or without treatment. Herniated disc tissue usually atrophies/degrades over time. Many studies, but not all, have shown gradual improvement in clinical function as the herniated disc decreases Evidence level: expert consensus Diagnosis and Imaging Question 3: What history and physical examination findings are diagnostic of lumbar disc herniated radiculopathy? Physical findings such as muscle strength, sensation, supine straight leg raise test, Lasegue’s sign, and contralateral Lasegue’s sign can help in the diagnosis of lumbar herniated disc radiculopathy. Grade of Recommendation: A The supine straight leg raise test, compared with the seated straight leg raise test, can be helpful in the diagnosis of lumbar disc herniation radiculopathy. Grade of Recommendation: B There is insufficient evidence to support or oppose the role of the cough-shock test, Bell test, overdraw test, femoral nerve pull test, slump test (Note 1), lumbar spine kinematics, and absent reflexes in the diagnosis of lumbar disc herniation radiculopathy. Recommendation level: I (insufficient evidence) Question 4: What is the most appropriate method for diagnosing lumbar disc herniation radiculopathy? When is it necessary to apply said method? There are no high-quality clinical studies demonstrating the advantages of imaging for the diagnosis of lumbar herniated disc radiculopathy. Work Group experts recommend MRI as the most appropriate noninvasive imaging test for patients with a history of lumbar disc herniated radiculopathy and positive physical exam findings. If there are contraindications for patients to undergo MRI, or if the results cannot be determined after testing, CT is recommended as the next best option. Level of Evidence: Expert Consensus Noninvasive MRI is recommended as the imaging test of choice for patients with a diagnosis of lumbar disc herniated radiculopathy and the presence of a corresponding history and positive physical examination findings. Grade of Recommendation: A CT, myelography, or CT myelography is recommended as the imaging test of choice for patients with a diagnosis of lumbar disc herniated radiculopathy and the presence of a corresponding history and positive physical examination findings. Grade of Recommendation: A Electrodiagnostic study for the diagnosis of nerve root compression is now more widely used in clinical practice, but the test does not identify the cause of nerve compression. The panel concluded that the preferred diagnostic option for lumbar disc herniation radiculopathy should continue to be axial imaging of the corresponding site, and that electrodiagnostic testing should only be used as an adjunct to identify other possible comorbidities. Level of Evidence: Expert Consensus Somatosensory excitation potentials can be used as an adjunct to imaging to determine the presence of nerve root compression, but the specificity of this test for diagnosing compressed segments is not high. Grade of Recommendation: B Electromyography, nerve conduction velocity, and F waves are of limited significance in the diagnosis of lumbar disc herniation radiculopathy. h-reflex waves are helpful in the diagnosis of S1 radiculopathy, but specificity is poor. Grade of Recommendation: B There is no clear clinical evidence for or against the use of motor excitation potentials or toe extensor reflexes in the diagnosis of lumbar disc herniation radiculopathy. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence for or against the use of thermal induction testing or liquid crystal displays in the diagnosis of lumbar disc herniated radiculopathy. Grade of Recommendation: I (Insufficient Evidence) Prognostic Indicators Question 5: What is the best indicator of prognosis after treatment of lumbar disc herniation radiculopathy? NASS has published a guideline book on this topic entitled: Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders, which can be found in the relevant book chapter. Medication or Intervention Question 6: What role does medication play in the treatment of lumbar disc herniation radiculopathy? Tumor necrosis factor alpha inhibitors are not recommended in patients with lumbar disc herniation radiculopathy. Grade of Recommendation: B There is no clear clinical evidence for or against the use of single intravenous hormones, guanethidine, 5-hydroxytryptamine agonists, gabapentin, and amitriptyline in patients with lumbar disc herniated radiculopathy. Recommendation Grade: I (insufficient evidence) Question 7: What role does physical therapy play in the management of lumbar disc herniation radiculopathy? There is no clear clinical evidence for or against the use of physical therapy/structured rehabilitation exercises as monotherapy for the treatment of lumbar disc herniated radiculopathy. GRADE OF RECOMMENDATION: I (INSUFFICIENT EVIDENCE) In the absence of conclusive evidence at this time, the Task Force recommends that a limited structured rehabilitation exercise strategy may be a treatment option for patients with mildly to moderately symptomatic lumbar herniated disc radiculopathy. LEVEL OF EVIDENCE: EXPERT CONSENSUS Question 8: What is the role of chiropractic in the management of lumbar disc herniation radiculopathy? Spinal manipulation alone can be a treatment option for patients with lumbar disc herniation radiculopathy. Grade of Recommendation: C There is no clear evidence for or against chiropractic being more effective than disc ablation. Grade of Recommendation: I (Insufficient Evidence) Question 9: What is the role of traction (manual or mechanical) in the treatment of lumbar disc herniation radiculopathy? There is no clear clinical evidence for or against the use of traction in patients with lumbar disc herniation radiculopathy. Grade of recommendation: I (insufficient evidence) Question 10: Are enhanced myelography-guided epidural hormone analog injections (ESIs) necessary for the treatment of lumbar disc herniated radiculopathy? Enhanced myelography-guided epidural hormone-like injections (ESIs) are recommended for the treatment of lumbar disc herniated radiculopathy. Recommendation Grade: A Question 11: What is the role of ESIs for the treatment of lumbar disc herniated radiculopathy? Transforaminal ESIs are recommended as a short-term pain control regimen in patients with lumbar herniated disc radiculopathy. GRADE OF RECOMMENDATION: A Transforaminal ESIs can be used as an alternative option for the treatment of lumbar herniated disc radiculopathy. GRADE OF RECOMMENDATION: C There is no clear clinical evidence for or against the efficacy of transforaminal ESI for the treatment of lumbar disc herniated radiculopathy after 12 months. Grade of Recommendation: I (Insufficient Evidence) Question 12: Is there an optimal time interval or injection dose for ESI for lumbar disc herniated radiculopathy? There is no clinical literature on this issue. Question 13: Does the route of injection of ESI affect the outcome of lumbar herniated disc radiculopathy treatment or increase the risk of injection? There is no clear clinical evidence for or against the superiority of one injection route over another. Recommendation Grade: I (Insufficient Evidence) Question 14: What is the role of various spinal interventions in the treatment of lumbar disc herniated radiculopathy? There is no clear clinical evidence for or against intradiscal ozone injection for the treatment of lumbar disc herniated radiculopathy. Grade of Recommendation: I (Insufficient Evidence) Endoscopic percutaneous discectomy can be used as a treatment for lumbar disc herniated radiculopathy. GRADE OF RECOMMENDATION: C Endoscopic percutaneous discectomy used in patients who have been carefully screened for indications can be effective in reducing the use of postoperative pain medications and improving patients’ low back discomfort. Grade of Recommendation: B Automated percutaneous discectomy can be used as a treatment for lumbar disc herniation radiculopathy. Grade of Recommendation: C There is no clear clinical evidence for or against automatic percutaneous discectomy being better than open discectomy. There is no clear clinical evidence for or against the use of ionized disc decompression (essentially equivalent to radiofrequency ablation)/nucleoplasty in patients with lumbar disc herniation radiculopathy. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence to support or oppose ionic disc decompression as a better treatment than transforaminal ESIs. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence to support or oppose transforaminal intravertebral disc injections of high-pressure saline and electrothermal disc decompression for the treatment of lumbar disc herniated radiculopathy. Recommendation Grade: I (Insufficient Evidence) Question 15: What is the role of adjunctive therapeutic measures such as bracing, electrical stimulation, acupuncture, and transcutaneous electrical stimulation in the treatment of lumbar disc herniated radiculopathy? There is no clear clinical evidence for or against the use of the above adjunctive therapeutic measures in the treatment of lumbar disc herniated radiculopathy. Recommendation Grade: I (Insufficient Evidence) Question 16: What is the likelihood that a patient diagnosed with lumbar disc herniated radiculopathy will have a good/good functional prognosis in the short term (less than 6 weeks), intermediate term (6 weeks to 2 years), or long term (greater than 2 years) when treated with the corresponding medication or intervention? Pharmacologic or interventional therapy improves the clinical functional prognosis for most patients with lumbar disc herniation radiculopathy. Grade of Recommendation: B Transforaminal ESIs improve the clinical functional prognosis of most patients with lumbar disc herniation radiculopathy. There is no clear clinical evidence for or against chiropractic care improving clinical prognosis in patients with lumbar disc herniation radiculopathy. years) or long-term (>2 years) likelihood of a good/good functional prognosis? Patient age (less than 40 years) and shorter clinical symptom duration (less than 3 months) are associated with a better clinical functional prognosis after percutaneous discectomy. LEVEL OF EVIDENCE: II The available research evidence does not suggest a significant prognostic difference when treating different types of lumbar herniated disc radiculopathy with transforaminal ESI. Level of Evidence: II/III The available research evidence suggests a negative correlation between the degree of nerve root compression and clinical functional prognosis. Level of Evidence: II/III There is no clear clinical evidence to correlate patient age with the efficacy of pharmacologic or interventional therapy. Grade of Recommendation: I (Insufficient Evidence) Question 18: What is the utility ratio of pharmacologic or interventional treatments for lumbar disc herniated radiculopathy? One study concluded that transforaminal ESI has a favorable utility ratio [46.47]. Surgical Treatment Question 19: Is there a clinical sign or symptom that suggests a favorable prognosis for surgical treatment of lumbar disc herniation radiculopathy? Preoperative evaluation of patients with lumbar disc herniation radiculopathy is recommended if depression is present. Patients with psychiatric depression have a poorer postoperative functional prognosis. Grade of Recommendation: B There is no clear clinical evidence for or against the correlation between the duration of symptoms in preoperative patients and the functional prognosis of lumbar herniated disc radiculopathy with cauda equina symptoms. Grade of Recommendation: B Question 20: What is the role of ESI or selective nerve blocks in the selection of patients for subsequent surgical treatment? There are no relevant studies on this question. Question 21: When is the optimal time for surgical intervention? Surgery is recommended within 6 months for patients with lumbar disc herniated radiculopathy whose symptoms are severe enough to require treatment by surgery. Available evidence suggests that patients with early surgical intervention (6 months-1 year) have faster postoperative recovery and a better long-term neurologic prognosis. Grade of Recommendation: B There is no clear clinical evidence for or against emergency spine surgery in patients with motor dysfunction due to disc herniation. GRADE OF RECOMMENDATION: I (Insufficient Evidence) QUESTION 22: Is discectomy for lumbar disc herniation radiculopathy more effective than pharmacologic or interventional therapy alone? There is evidence that for patients with lumbar herniated disc radiculopathy whose symptoms are severe enough to require surgical intervention, discectomy treatment provides better symptomatic relief than drug or interventional therapy. In patients with mild clinical symptoms, surgery or pharmacologic/interventional treatments may result in better short- and long-term functional improvement. GRADE OF RECOMMENDATION: B Automated percutaneous discectomy can achieve similar results to open discectomy in patients with strictly selected indications. However, this entry is not applicable to all patients. Level of Evidence: II/III There is no clear clinical evidence for or against chiropractic care as an alternative treatment for patients with severe symptoms requiring discectomy. Level of Recommendation: I (Insufficient Evidence) Question 23: Are there specific clinical situations in which lumbar fusion is necessary to achieve a favorable functional prognosis? There is no clear clinical evidence for or against spinal fusion in specific patients with lumbar disc herniation radiculopathy. Recommendation Grade: I (Insufficient Evidence) Question 24: Are there different clinical prognoses or complications associated with different surgical approaches for the treatment of lumbar disc herniated radiculopathy? When a patient is indicated for surgery, either resection of the bone block for decompression or radical discectomy for decompression may be chosen, as there is no significant difference in the rate of reherniation between the two. GRADE OF RECOMMENDATION: B There is no clear clinical evidence for or against osteotomy or discectomy for the relief of chronic low back pain symptoms in patients with lumbar disc herniation radiculopathy requiring surgical treatment. GRADE OF RECOMMENDATION: I (INSUFFICIENT EVIDENCE) In patients with lumbar herniated disc radiculopathy requiring surgical treatment, discoscopic treatment can achieve the same results as open disc surgical treatment. GRADE OF RECOMMENDATION: B There is no clear clinical evidence for or against the idea that medial synovectomy for lumbar disc herniated radiculopathy improves functional prognosis. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence to support or oppose new surgical approaches for the treatment of radiculopathy due to extreme lateral disc herniation. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence for or against access discectomy to achieve a better functional prognosis than open discectomy. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence for or against the use of glucocorticoids or/and fentanyl after lumbar decompression to improve perioperative pain in patients for short periods of time. GRADE OF RECOMMENDATION: I (INSUFFICIENT EVIDENCE) The application of glucocorticoids or/and fentanyl after lumbar decompression is not recommended to improve the patient’s postoperative pain in the long term. GRADE OF RECOMMENDATION: B There is no clear clinical evidence for or against the application of localized fat flap coverage at the decompression site after lumbar decompression. Grade of Recommendation: I (Insufficient Evidence) There is no clear clinical evidence to support or oppose the use of Oxiplex/SP gel or ADCON-L in discectomy. Recommendation Grade: I (insufficient evidence) Question 25: What is the short-term (1-4 years) and long-term (>4 years) functional prognosis for surgical treatment? In patients with lumbar disc herniated radiculopathy requiring surgical treatment, decompressive surgery may provide better short-term symptom relief than pharmacologic or interventional therapy. Grade of Recommendation: B Decompressive surgery may provide long-term symptomatic relief. However, it should be noted that for some patients (23-28%) chronic back or leg pain may develop after surgery. LEVEL OF EVIDENCE: IV QUESTION 26: Is there a difference in the clinical functional prognosis or complications of surgical treatment of lumbar disc herniation radiculopathy across providers? There are no relevant studies on this question. Value of Surgical Treatment of the Spine Question 27: What is the utility of surgery for the treatment of lumbar disc herniated radiculopathy? There are a number of studies suggesting that surgical treatment has a better utility ratio in patients who are rigorously selected for surgical indications. Question 28: Do different surgical approaches affect the benefit of treating lumbar disc herniation radiculopathy? There are no relevant studies on this question. Question 29: Do different health care providers affect the benefit of lumbar disc herniation radiculopathy? There are no studies on this question.