Evolving Paradigms in Lumbar Disc Herniation: From Prediction to Precision Surgery

Lumbar disc herniation (LDH) remains a leading cause of radicular pain and disability worldwide. 1Despite the familiarity of this condition in clinical practice, persistent challenges continue to affect patient management: variable symptom severity despite similar imaging findings, unpredictable rates of spontaneous resorption, and heterogeneous outcomes following both conservative and surgical treatments. 2 Current clinical approaches still rely primarily on history, physical examination, and magnetic resonance imaging evidence of neural compression.However, these methods alone often fail to fully explain prognosis or guide optimal timing for intervention. 3,4As a result, the field is increasingly moving toward integrated and predictive models of care, combining morphology with biological, biomechanical, psychosocial, and technological insights.This Special Issue addresses these challenges by integrating evidence across several complementary domains: Natural history and spontaneous resorption: Improved understanding of when and how disc herniation resorption occurs provides a biological rationale for conservative management in selected patients and highlights imaging and inflammatory mechanisms underlying disc regression. Biomechanics and mechanobiology: Advances in the biomechanical characterization of disc injury are clarifying how mechanical loading, tissue failure patterns, and cellular responses interact to drive herniation, degeneration, and regenerative potential. Risk stratification and recurrence prediction: Systematic evidence on preoperative clinical and radiographic risk factors offers critical insight into predictors of recurrent LDH, supporting more informed surgical decision-making and follow-up strategies. Emerging molecular biomarkers: Circulating inflammatory and molecular signatures are opening new avenues for patient stratification, outcome prediction, and the future development of biologically informed therapies. Microbiome and the gut-spine axis: Growing evidence suggests that gut microbiota may influence systemic inflammation, pain modulation, and disc degeneration, introducing a novel biological dimension to LDH pathophysiology. Optimization of surgical techniques: Comparative analyses of surgical approaches, including the expanding role of endoscopic discectomy, reflect the ongoing evolution toward Neurospine