What is the management approach for Prolapsed Intervertebral Disc (PIVD)?

Management Approach for Prolapsed Intervertebral Disc (PIVD)

Conservative management should be the first-line approach for PIVD, consisting of medication management, physical therapy, and activity modification for 6-8 weeks before considering surgical options. 1

Initial Assessment and Diagnosis

• Perform thorough neurological examination to identify:
  • Level of disc herniation
  • Presence of motor weakness
  • Sensory changes in affected dermatomes
  • Reflex abnormalities
  • Signs of spinal cord compression (if cervical or thoracic PIVD)

Management Algorithm

Step 1: Conservative Management (First 6-8 weeks)

Medication Management

• First-line: NSAIDs at maximum tolerated dose for 2-4 weeks 1
  • Naproxen 375-1100 mg/day
  • Diclofenac 150 mg/day
  • Ibuprofen 1800 mg/day
  • Consider GI protection with proton pump inhibitors if risk factors present
• For muscle spasm: Short-term muscle relaxants (e.g., cyclobenzaprine)
• For severe pain: Short-term opioids (≤1 week)
• For neuropathic pain: Consider gabapentin or pregabalin if radicular symptoms persist

Physical Therapy

• Structured program focusing on:
  • Cervical/lumbar strengthening exercises
  • Range of motion exercises
  • Core stabilization
  • Postural correction
  • McKenzie method exercises (extension-based for most disc herniations) 2

Activity Modification

• Avoid activities that exacerbate pain
• Implement ergonomic adjustments at workplace
• Maintain light activity rather than strict bed rest
• Use proper body mechanics for lifting and daily activities

Step 2: If Limited Improvement After 2-4 Weeks

• Consider epidural steroid injections for persistent radicular symptoms 1
• Continue physical therapy with progression of exercises
• Reassess medication management

Step 3: Surgical Evaluation (If Conservative Management Fails)

Consider surgical referral for: 1, 3

• Persistent moderate to severe symptoms after 6-8 weeks of conservative management
• Progressive neurological deficits
• Cauda equina syndrome (emergency)
• Severe motor weakness (>3/5)
• Intractable pain unresponsive to conservative measures

Special Considerations

Cervical PIVD

• More careful monitoring required due to risk of spinal cord compression
• May present with both upper and lower extremity symptoms
• Potential for respiratory compromise with high cervical lesions 1

Lumbar PIVD

• Most common location (especially L4-L5, L5-S1)
• Better prognosis with conservative management compared to cervical PIVD
• 80-90% of patients improve with conservative management 4, 5

Monitoring and Follow-up

• Regular clinical assessment every 2-4 weeks during conservative management
• Use validated tools to assess progress (e.g., Oswestry Disability Index)
• Consider repeat imaging only if symptoms worsen or new neurological deficits develop

Prognosis

• Approximately 80% of patients experience symptom resolution with appropriate conservative treatment 1
• Surgical outcomes are better for patients with predominant radicular symptoms rather than back pain 5
• Long-term outcomes (>5 years) are similar between conservative and surgical management for most patients without severe neurological deficits 5

Pitfalls to Avoid

• Prolonged bed rest (>48 hours) may worsen outcomes
• Overreliance on imaging findings rather than clinical presentation
• Delayed surgical referral for progressive neurological deficits
• Long-term use of opioids or glucocorticoids 1
• Premature return to high-impact activities

Conservative management with appropriate medication, physical therapy, and activity modification remains the cornerstone of PIVD treatment, with surgery reserved for specific indications when conservative measures fail.