From the Guidelines
For patients with a herniated disc, conservative management with noninvasive treatments should be the initial approach, with surgery or epidural steroid injections considered only if symptoms persist or worsen after 6-8 weeks. The management of a herniated disc typically involves a step-wise approach, starting with conservative measures.
- Initial management includes:
- Rest for 1-2 days, then gradual increase in activity as tolerated
- Pain management with NSAIDs, such as ibuprofen 400-800 mg every 6-8 hours or naproxen 500 mg twice daily, and acetaminophen 500-1000 mg every 6 hours as needed 1
- Physical therapy, 2-3 times per week for 4-6 weeks, focusing on core strengthening and flexibility exercises
- Ice/heat therapy, applied for 15-20 minutes every 2-3 hours
- Lifestyle modifications, including maintaining good posture, using proper lifting techniques, and avoiding prolonged sitting
- If symptoms persist or worsen after 6-8 weeks, consider:
- Epidural steroid injections, 1-3 injections, spaced 2-4 weeks apart
- Surgical consultation if conservative measures fail after 3 months or if neurological deficits worsen, as recommended by the American College of Physicians and the American Pain Society 1 This approach is supported by the natural history of lumbar disc herniation with radiculopathy, which shows improvement within the first 4 weeks with noninvasive management in most patients 1. Magnetic resonance imaging (MRI) is recommended for evaluating patients with persistent back and leg pain who are potential candidates for surgery or epidural steroid injection. It is essential to note that there is no compelling evidence that routine imaging affects treatment decisions or improves outcomes, and therefore, imaging should be reserved for patients who are potential candidates for invasive procedures 1. By following this approach, patients with a herniated disc can receive effective management, minimizing the risk of unnecessary procedures and optimizing outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Management of Herniated Disc
The management of a herniated disc can be divided into non-surgical and surgical approaches.
- Non-surgical approaches are considered the preferred initial management methods as they are proven to be efficient in reducing both pain and disability in the absence of any red flags 2.
- The following interventions have been identified to yield moderate evidence of effectiveness for the conservative treatment of lumbar disc herniation:
- Patient education and self-management
- McKenzie method
- Mobilization and manipulation
- Exercise therapy
- Traction (short-term outcomes)
- Neural mobilization
- Epidural injections 2
- Initial treatment for extreme lateral disc herniation is bed rest and NSAIDs, with surgery considered if conservative therapy fails 3.
- Continued conservative therapy can be a cost-effective option for patients who have not improved or have deteriorated within the first 3 months of initial conservative therapy 4.
- Conservative management of lumbar disk herniation may include bed rest, physical therapy, comfortable positioning, manipulation, drug therapy, and hospitalization if necessary 5.
Surgical Management
- Surgical treatment is considered when conservative treatment does not sufficiently improve clinical symptoms, such as progressive or persisting neurological deficits, or persisting pain that alters the quality of the patient's life 6.
- The results of surgery are strongly dependent on the preoperative duration of symptoms, with poorer surgical results associated with increasing preoperative duration of symptoms 6.
- There are different surgical techniques and approach strategies, including endoscopic and microsurgical techniques, with the choice determined by the morphology and location of the herniated disc 6.
- Good clinical outcomes in meta-analyses/large case series are between 80-95% 6.