From the Research
The initial treatment for a patient with L4-L5 left posterolateral disc herniation is conservative management, as this approach has been shown to be effective in reducing symptoms and improving quality of life for the majority of patients 1. This approach typically begins with a combination of relative rest, activity modification, and pain control medications. Patients should avoid activities that exacerbate symptoms while maintaining some level of movement to prevent deconditioning.
Key Components of Conservative Management
- For pain management, start with acetaminophen 500-1000mg every 6 hours as needed, and add NSAIDs such as ibuprofen 400-600mg three times daily with food or naproxen 500mg twice daily for 1-2 weeks.
- For more severe pain, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime may be prescribed for 1-2 weeks.
- Physical therapy focusing on core strengthening, lumbar stabilization exercises, and stretching should be initiated within 1-2 weeks of symptom onset.
Rationale and Expected Outcomes
This conservative approach is effective for approximately 90% of patients with disc herniations, as the natural history of disc herniation tends toward improvement over time 2. The rationale behind this approach is to reduce inflammation around the compressed nerve root while maintaining function and promoting healing. If symptoms persist beyond 6 weeks or if there are progressive neurological deficits, severe pain, or cauda equina syndrome, further interventions such as epidural steroid injections or surgical consultation may be warranted 3, 4. It's also important to consider the potential for non-adjacent, isolated radicular symptoms, as seen in cases where an L2/3 disc herniation causes L5 radiculopathy 5.