What are the next steps for a patient with a herniated disc after receiving Magnetic Resonance Imaging (MRI) results?

From the Guidelines

The next steps for a patient with a confirmed herniated disc via MRI should prioritize conservative management, with a focus on noninvasive treatments and careful consideration of invasive interventions, as recommended by the American College of Physicians and the American Pain Society 1.

Initial Management

The patient should begin with a combination of rest and gentle activity modification to avoid exacerbating symptoms. A short course of oral NSAIDs, such as ibuprofen, can be prescribed to reduce inflammation and pain, as suggested by the guideline 1. Additionally, physical therapy sessions focusing on core strengthening, flexibility, and proper body mechanics can be beneficial.

Progressive Treatment Approach

If pain persists, consider adding a muscle relaxant or a short course of oral corticosteroids. It is essential to educate the patient on proper ergonomics and posture to prevent further injury. The natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management 1.

Invasive Interventions

For patients with persistent radicular symptoms despite noninvasive therapy, discectomy or epidural steroids are potential treatment options 1. However, these decisions should be based on the clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks, and costs, and will generally require specialist input.

Key Considerations

• The guideline recommends MRI (preferred) or CT for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions 1.
• Clinicians should be aware that findings on MRI or CT are often nonspecific, and treatment decisions should be based on clinical correlation and patient preferences.
• The treatment approach should prioritize conservative management, with a focus on noninvasive treatments and careful consideration of invasive interventions.

From the Research

Next Steps for a Patient with a Herniated Disc

After receiving Magnetic Resonance Imaging (MRI) results, the next steps for a patient with a herniated disc may include:

• Conservative management, which can involve patient education, acute inflammation control, closed disc reduction, remedial therapeutic care, and individualized rehabilitation training for home-based care exercise 2
• A combination of manual therapy and rehabilitative exercise, which can help achieve a positive long-term outcome 2
• Bed rest, physical therapy, comfortable positioning, manipulation, drug therapy, and hospitalization (if necessary) to manage the acute phase of lumbar disk herniation 3
• Alternative treatments such as percutaneous diskectomy, which may be considered as a significant alternative to traditional lumbar laminectomy 3

Conservative Therapy

Conservative therapy methods are usually used as the first treatment option for lumbar disc herniation, and surgical interventions should only be considered in special symptom constellations 4

• Conservative treatment methods can lead to a significant reduction in pain and improvement in functional abilities in the majority of patients 4
• The combination of different treatment approaches, such as physiotherapy, drug treatment, manual therapy, and injection therapies, can improve treatment outcomes 4

Surgical Intervention

Surgical treatment may be considered for patients with progressive or persisting neurological deficits, or persisting pain that alters the quality of life 5

• The results of surgery are strongly dependent on the preoperative duration of symptoms, and poorer surgical results are associated with increasing preoperative duration of symptoms 5
• Minimally invasive techniques, such as endoscopic and microsurgical approaches, can lead to comparable clinical results and allow for early mobilization and return to work 5

Cost-Effectiveness

The cost-effectiveness of extended conservative therapy versus surgical intervention in the management of herniated lumbar intervertebral disc has been studied, and no significant difference was found in outcome or costs between the two treatment modalities 6

• However, conservatively treated patients may miss significantly more work, and the option to undergo continued conservative treatment should be made available to patients who do not respond to initial trial of conservative therapy 6