The problem with MRI is
that we all have small (and sometimes even large) herniated discs that are
asymptomatic. So usually the MRI is not done until there is a surgical
indication. The usual surgical indication is muscle weakness, with
everything else (pain and numbness) being managed conservatively. But when
weakness becomes apparent, then an MRI is done and if there is an operable
herniated disc pressing against the appropriate nerve root thatinnervates
the weak muscles then surgery is indicated. This approach only works well
if the patient is being followed closely for weakness. Les wasn't followed
closely (which is really only possible if the patients are admitted to the
hospital). He never had a careful muscle power exam until he was almost
paralyzed; by then it was too late.

Interestingly when surgeons have back pain and a herniated disk, in my
experience, they always get an MRI and have themselves operated on
immediately, even when there is only back pain and/or numbness and no
weakness. The reason surgery is always a difficult judgement call when
there is no muscle weakness is that a small percentage of patients that are
operated on develop a bad scarring problem at the site of the surgery that
causes severe intractable chronic pain that can be disabling and is
presently untreatable (as more surgery generally tends to make the scarring
worse). So even without managed care, the first instincts of many
physicians are to try to manage conservatively.

I tend to agree with you though that in retrospect Les could have been
managed more aggressively. Since MRI's are totally safe and Les was a
triathloner, in severe pain, and had radicular signs (that is he had
numbness and loss of reflexes in an S1 nerve distribution), he might have
been given an MRI right away (if money had been no object). Then if the
MRI showed a huge herniation, he could have been operated on.


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