What is the best nonsurgical approach to herniated disk in a patient with bilateral sciatic-pain radiation?
—Richard D. Miller, MD, Miami

A targeted epidural steroid injection at the appropriate level of the lumbar spine may provide adequate pain relief.

If the MRI demonstrates severe multilevel changes with nerve impingement, a caudal block may be preferred. Once the acute symptoms abate, a formal course of rehabilitation therapy emphasizing core stabilization exercises should be encouraged. For breakthrough pain, nonsteroidal anti-inflammatory drugs can be used as needed. If pain recurs following the first epidural steroid injection, a second injection can be performed four to six weeks later.
—Simon M. Helfgott, MD, associate professor of medicine, Division of Rheumatology, Harvard Medical School, Boston (112-13)

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