What is the best treatment approach for a patient with a large disc protrusion?

From the Guidelines

The best treatment approach for a patient with a large disc protrusion typically begins with conservative management for 6-8 weeks, including relative rest, physical therapy, and pain medications. Initial pain control may include NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), possibly combined with muscle relaxants such as cyclobenzaprine (5-10mg three times daily) for acute spasm. Physical therapy should focus on core strengthening, flexibility, and proper body mechanics. For severe pain, a short course of oral steroids like prednisone (starting at 60mg daily and tapering over 5-7 days) may help reduce inflammation. If conservative measures fail to provide relief after 6-8 weeks, or if neurological deficits worsen (such as progressive weakness, bowel/bladder dysfunction, or severe uncontrolled pain), surgical intervention may be necessary. The specific surgical approach depends on the location and size of the protrusion, with options including microdiscectomy or laminectomy. Surgery is generally reserved for cases with persistent symptoms or neurological compromise, as many disc protrusions will improve with conservative care alone, as supported by the most recent guidelines from the American College of Radiology 1. The rationale for this stepped approach is that disc material can naturally resorb over time, and the body can adapt to the altered disc anatomy without surgical intervention in many cases. Key considerations in the management of large disc protrusions include:

• Initial assessment for red flags or indications for immediate imaging or surgical intervention
• Conservative management as the first line of treatment
• Use of imaging studies like MRI or CT only when necessary for surgical planning or when conservative management fails
• Patient education on the natural history of disc protrusions and the potential for improvement with conservative care
• Multidisciplinary approach to management, including physical therapy, pain management, and surgical consultation when necessary.

From the Research

Treatment Approaches for Large Disc Protrusion

• The treatment of large disc protrusion often involves a stepwise approach, starting with nonoperative measures such as oral analgesic medication, activity modification, and physical therapy 2.
• If nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection 2.
• A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy 2, 3.
• Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation, but it may not be as effective as discectomy in reducing symptoms and disability associated with a large herniation of the lumbar disc 3.
• Manipulative therapy, including spinal manipulation, can be a conservative approach to treat lower back pain with sciatica, and may be considered before surgical consultation 4.

Long-Term Outcomes

• Long-term outcomes for patients with lumbar radicular pain due to intervertebral disc herniation are poorly described, but studies suggest that recurrence rates are high regardless of treatment received 5.
• A study found that after 5 years, 76.9% of patients who underwent lumbar transforaminal epidural steroid injections had a history of recurrent pain, but only 23.1% had current pain 5.
• Surgery may be necessary for some patients, but the complication rate for surgical approaches can be higher, especially for transthoracic approaches 6.

Surgical Treatment

• Surgical treatment is indicated when the patient has severe back pain, stubborn intercostal neuralgia, or neurological deficits 6.
• The selection of the surgical approach is essential, and mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision 6.
• Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction 6.