What are the treatment options for a bulging disk?

Treatment Options for Bulging Disk

For most patients with a bulging disk, conservative management should be the initial approach as the natural history shows improvement within the first 4 weeks with noninvasive treatment. 1

Initial Conservative Management

• Physical therapy focusing on core strengthening and flexibility exercises should be the cornerstone of initial treatment for degenerative disk disease 2
• Patients should be advised to remain active, which is more effective than resting in bed for acute or subacute low back pain 1
• If severe symptoms require periods of bed rest, patients should be encouraged to return to normal activities as soon as possible 1
• Self-care education materials based on evidence-based guidelines (such as The Back Book) are recommended as an inexpensive and efficient method to supplement clinician advice 1
• Most lumbar disc herniations with radiculopathy will improve within the first 4 weeks with noninvasive management 1

Progression of Treatment

• For persistent symptoms beyond 6 weeks of conservative management, further evaluation may be warranted 3
• MRI (preferred) or CT is recommended for evaluating patients with persistent back and leg pain who might be candidates for invasive interventions 1
• Imaging should be reserved for patients who are potential candidates for surgery or epidural steroid injection, as routine imaging does not improve outcomes 1

Advanced Treatment Options

Epidural Steroid Injections

• For persistent radicular symptoms despite conservative therapy, epidural steroids are a potential treatment option 1, 3
• These injections can provide short-term relief but have moderate evidence for effectiveness 3, 4

Surgical Options

• Surgery should be considered only after failure of conservative management (typically at least 6 weeks) 2, 3
• Discectomy may be appropriate for patients with persistent radicular symptoms and corresponding imaging findings 1
• Surgery may improve symptoms more quickly than continued conservative management, though long-term outcomes (after 2 years) are similar 3
• Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with isolated herniated discs causing radiculopathy 1
• Fusion may be considered only in specific circumstances: significant chronic axial back pain, manual laborers, severe degenerative changes, or instability associated with radiculopathy 1

Prognosis and Natural History

• Patients should be informed of the generally favorable prognosis of acute low back pain with or without sciatica 1
• The rate of spontaneous regression varies by herniation type: 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and only 13% for disc bulging 5
• Complete resolution occurs in 43% of sequestrated discs and 15% of extruded discs 5

Important Considerations

• Findings on MRI or CT (such as bulging disc without nerve root impingement) are often nonspecific and should be correlated with clinical symptoms 1
• Treatment decisions should be based on clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, and risks 1
• Meta-analyses comparing surgical procedures versus non-surgical treatment have shown similar long-term outcomes, highlighting the importance of appropriate patient selection 2
• Dynamic bulging of intervertebral discs may change with different postures, with extension potentially causing more posterior bulging in degenerative discs 6