From the Guidelines
Treatment for an L5-S1 disc extrusion impinging on the S1 nerve should initially focus on conservative management, including rest, physical therapy, and pain management, before considering surgical intervention, as recommended by the most recent guidelines 1. The initial approach to treating an L5-S1 disc extrusion impinging on the S1 nerve involves conservative management strategies. This typically includes:
- Rest for 24-48 hours followed by a gradual return to activities
- Over-the-counter pain medications such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) to reduce inflammation
- Physical therapy focusing on core strengthening, flexibility, and proper body mechanics, started within 1-2 weeks of symptom onset For more severe pain, prescription medications may include muscle relaxants like cyclobenzaprine (5-10mg three times daily) for 1-2 weeks, or short-term opioids if necessary. Epidural steroid injections can provide temporary relief by reducing inflammation around the nerve root. These conservative measures should be tried for 6-12 weeks before considering surgery, as the natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management 1. Surgical options, such as microdiscectomy to remove the protruding disc material or minimally invasive procedures, are typically reserved for patients with severe or progressive neurological deficits, intractable pain despite conservative treatment, or cauda equina syndrome, which requires emergency intervention 1. The effectiveness of treatment can be gauged by improvement in symptoms such as pain radiating down the back of the leg, numbness or tingling in the foot, and possibly weakness in the calf muscles or difficulty with toe-off while walking. It's also important to note that findings on MRI or CT, such as bulging disc without nerve root impingement, are often nonspecific, and decisions should be based on the clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks, and costs, as recommended by guidelines 1. However, the most recent and highest quality study 1 provides the best guidance for current practice.