What is a Bulging Disc and How to Decrease Pain
A bulging disc is a spinal condition where the intervertebral disc extends beyond its normal boundaries (often associated with radial tears in the annulus fibrosus), and you should start with conservative management including staying active, physical therapy focused on core strengthening, and NSAIDs like ibuprofen 400mg every 4-6 hours, as most patients improve within 4-6 weeks without surgery. 1, 2, 3
Understanding Bulging Discs
A bulging disc occurs when the intervertebral disc protrudes beyond its normal anatomical position. Contrary to older concepts, most bulging discs actually have radial tears in the annulus fibrosus rather than an intact outer layer—84% of disks with radial tears show bulging greater than 2.5mm. 4 Importantly, disc abnormalities including bulges are commonly found in asymptomatic patients, meaning imaging findings don't always correlate with pain. 5
Initial Conservative Treatment (First 4-6 Weeks)
You should NOT order imaging initially unless red flags are present, as routine imaging provides no clinical benefit and doesn't improve outcomes. 1 The natural history strongly favors conservative management:
Activity Modification
- Stay active rather than resting in bed—this is more effective for acute pain. 1
- Return to normal activities as soon as possible, even if brief bed rest was needed for severe symptoms. 1
- Avoid excessive or irritating movements temporarily. 5
Physical Therapy
- Core strengthening and flexibility exercises should be the cornerstone of treatment. 1, 6
- Manual mobilization and therapeutic exercises are evidence-based options. 5
Medication
- Ibuprofen 400mg every 4-6 hours as needed (maximum 3200mg daily, though doses above 400mg show no additional benefit for pain relief). 2
- Take with meals or milk if gastrointestinal complaints occur. 2
- Other options include muscle relaxants, tricyclic antidepressants, or anticonvulsants for neuropathic symptoms. 5
Expected Timeline
60-80% of patients improve within 6-12 weeks, and 80-90% improve over the long term (≥1 year) with conservative treatment alone. 7 Most lumbar disc herniations with radiculopathy improve within the first 4 weeks. 1
When to Progress Beyond Conservative Care
Imaging Indications (After 4-6 Weeks)
Order MRI or CT only if symptoms persist beyond 4-6 weeks AND the patient is a potential candidate for epidural steroid injection or surgery. 1 Imaging findings must be correlated with clinical symptoms, as abnormalities are common in pain-free individuals. 5, 1
Epidural Steroid Injections
For persistent radicular symptoms despite 6+ weeks of conservative therapy, epidural steroid injections can provide relief and help 77% of surgical candidates avoid surgery for 12-27 months. 1, 8 These injections offer short-term relief but are a reasonable option before considering surgery. 3, 8
Surgical Indications
Surgery should be considered in specific scenarios:
Emergent (within 24-48 hours):
- Cauda equina syndrome (bladder/bowel dysfunction). 7
Urgent (within 3 days):
- Severe motor deficits (MRC ≤3/5), as longer symptom duration reduces recovery chances. 7
- Progressive neurological deficits despite conservative care. 6
Elective (after 6+ months):
- Persistent radicular symptoms with corresponding imaging findings after at least 6 months of comprehensive conservative therapy. 1, 6
- Intractable, disabling pain refractory to all conservative measures. 6
Important Caveats
Surgical and conservative treatment show similar outcomes at 2 years, so patient preference and disability severity should guide decisions. 3 Surgery provides faster symptom resolution initially but doesn't change long-term outcomes. 9, 3
Lumbar fusion is NOT recommended for isolated disc herniations causing radiculopathy—simple discectomy is sufficient unless there's significant chronic axial back pain, instability, or recurrent herniations. 1, 6
Symptom duration matters: the longer you wait with motor deficits, the lower the recovery rate (33-75% depending on timing and severity). 7