What is the recommended treatment for Lumbar Disc Herniation (LDH)?

Management of Lumbar Disc Herniation

For patients with lumbar disc herniation, initial management should focus on conservative treatment for 6 weeks, including non-opioid analgesics, NSAIDs, and physical therapy, with surgery reserved for cases with persistent symptoms, progressive neurological deficits, or cauda equina syndrome. 1, 2

Diagnostic Approach

• Classification: Determine if the patient falls into one of three categories:

  • Nonspecific low back pain
  • Back pain with radiculopathy or spinal stenosis (including disc herniation)
  • Back pain with another specific spinal cause 1

• Key Assessment Elements:

  • Evaluate for red flags requiring urgent intervention:

    • Progressive neurological deficits
    • Cauda equina syndrome (90% present with urinary retention)
    • Fever or signs of infection
    • History of cancer
    • Significant trauma 1, 3

  • Neurological Examination:

    • Straight-leg-raise test (high sensitivity 91% but modest specificity 26%)
    • Crossed straight-leg-raise test (higher specificity 88% but lower sensitivity 29%)
    • Assess knee strength and reflexes (L4 nerve root)
    • Evaluate great toe and foot dorsiflexion strength (L5 nerve root)
    • Check foot plantarflexion and ankle reflexes (S1 nerve root) 1

Treatment Algorithm

First-Line Management (0-6 weeks)

1. Non-pharmacologic interventions:

   • Advise patients to stay active 2
   • Physical therapy with supervised exercises 3
   • Manual therapy/spinal manipulation 3
   • Heat therapy for acute pain 3
   • McKenzie method exercises 4
   • Neural mobilization techniques 4

2. Pharmacologic management:

   • Non-opioid analgesics and NSAIDs (most commonly used - 90.5% of cases) 5
   • Consider topical NSAIDs with/without menthol gel (strongest benefit-harm ratio) 3
   • Pregabalin may be beneficial (used in 41.4% of cases) 5

3. Interventional options:

   • Epidural steroid injections for short-term relief
     • Transforaminal approach preferred (51.7% of specialists) 5
     • Interlaminar approach (27.2% of specialists) 5

Management After 6 Weeks (If Symptoms Persist)

1. Imaging:

   • MRI of the lumbar spine without contrast is the preferred imaging modality 3
   • Consider upright radiographs with flexion/extension views to assess segmental motion 3

2. Surgical consideration for:

   • Cauda equina syndrome (medical emergency)
   • Progressive neurological deficits
   • Intractable pain despite conservative management
   • Persistent symptoms after 6-12 weeks of conservative treatment 5, 2, 6

3. Surgical options:

   • Traditional microdiscectomy (most common - 68.5% of surgeons) 5
   • Endoscopic disc resection (7.5% of surgeons) 5
   • Tubular discectomy (6.4% of surgeons) 5

Important Clinical Considerations

• Natural History: Most lumbar disc herniations improve within 4-6 weeks with conservative management 2, 6

• Timing of Surgical Referral:

  • Private practice surgeons often consider conservative treatment failure at 3-6 weeks
  • Public sector surgeons typically wait 6-12 weeks before considering surgery 5

• Long-term Outcomes: No significant difference in outcomes between surgical and conservative treatment after 2 years, making patient preference and disability severity important factors in treatment decisions 2

• Surgical Technique: Refined surgical technique with removal of the extruded fragment and preservation of the ligamentum flavum resolves sciatic symptoms and reduces long-term recurrence risk 6

Evidence-Based Effectiveness of Conservative Treatments

• Moderate evidence (Level B) supports:

  • Patient education and self-management
  • McKenzie method
  • Mobilization and manipulation
  • Exercise therapy
  • Traction (short-term outcomes)
  • Neural mobilization
  • Epidural injections 4

• Weak evidence (Level C) for:

  • Traction for long-term outcomes
  • Dry needling 4

• Conflicting or no evidence (Level D) for:

  • Electro-diagnostic-based management
  • Laser and ultrasound
  • Electrotherapy 4