Prolapsed intervertebral disc is common—it is seen in up to a quarter of magnetic resonance scans and can be detected even in asymptomatic adults.1 Disc prolapse is genetically driven—twin studies indicate that at least 60% of the variance can be explained on genetic grounds and not by the commonly assumed environmental factors (work, trauma, exposure to excessive driving, smoking, and so on).2 In the linked randomised controlled trial, Peul and colleagues compare the effects of early surgery with conservative management at two years in 283 patients who have had sciatica for six to 12 weeks.3 A second study by van den Hout and colleagues compares the costs of each approach.4

Current guidelines indicate that radicular pain should improve within six to eight weeks with conservative management.5 Surgery should be performed before eight weeks only in patients with progressive neurological deficit, which can be detected by magnetic resonance imaging. Some people will have radicular pain and no prolapse. Epidural local anaesthetic and steroids may benefit these patients, although the evidence base is weak.6

Management problems arise if severe pain lasts for longer than eight weeks. A few trials and many guidelines indicate that even …