What is the treatment for disc herniation?

Treatment for Disc Herniation

Start with at least 4-6 weeks of conservative management including immediate physical therapy and activity continuation, as most disc herniations resolve spontaneously and long-term outcomes are similar between surgical and non-surgical approaches. 1

Initial Conservative Management (First-Line for All Patients)

• Initiate physical therapy immediately focusing on core strengthening and flexibility exercises—this is the cornerstone of treatment, not bed rest 1
• Patients must remain active rather than resting in bed, as activity is more effective for acute or subacute low back pain 1
• Continue conservative management for at least 4-6 weeks, as most lumbar disc herniations with radiculopathy improve within the first 4 weeks 1
• Provide evidence-based self-care education materials to supplement clinical advice 1

The American College of Physicians strongly recommends this conservative approach first, as most bulging discs improve with noninvasive treatment and surgical versus non-surgical outcomes are similar long-term 1, 2.

Red Flags Requiring Immediate Surgical Consultation

Evaluate urgently for these conditions—do not delay:

• Urinary retention (90% sensitivity for cauda equina syndrome)—this requires emergency intervention to prevent permanent neurological damage 1, 3
• Progressive neurological deficits warrant urgent surgical consultation 1, 3
• Cauda equina syndrome represents a medical emergency 4

When to Order Imaging

• Reserve imaging only for patients who are potential surgical or epidural injection candidates after failed conservative therapy 1
• Do not order imaging before completing 4-6 weeks of conservative therapy unless red flags exist 1
• Imaging findings must correlate with clinical symptoms—disc abnormalities are common in asymptomatic individuals, and over-reliance on imaging leads to unnecessary surgery 1, 3

Progression to Advanced Treatment

If symptoms persist after 6 months of comprehensive conservative therapy:

• Consider epidural steroid injections for persistent radicular symptoms (provides short-term relief) 1, 2

• Surgery should be considered only when:

  • Nonoperative treatments fail after at least 6 months 1, 3
  • Progressive neurological deficits are present 1, 3
  • Cauda equina syndrome develops 1, 3
  • Severe disabling pain is refractory to 6 months of conservative therapy 3, 5

• Discectomy may be appropriate for patients with persistent radicular symptoms and corresponding imaging findings 1

The American College of Physicians emphasizes that surgical treatment provides faster symptom relief, but outcomes at 2 years are equivalent to conservative management, making patient preference and disability severity important considerations 2, 6.

Critical Surgical Decision: Fusion vs. Discectomy Alone

Lumbar spinal fusion is NOT recommended as routine treatment following discectomy for isolated herniated discs causing radiculopathy 1, 3, 7

• There is Level III and IV evidence showing no benefit to adding fusion during routine discectomy—it only increases complexity and complications 3
• Decompression without fusion is typically sufficient for patients with primarily radicular symptoms 7

Fusion should be considered only in these specific circumstances:

• Significant chronic axial back pain with 1-2 level degenerative disc disease 7
• Manual labor occupations (89% vs. 53% work maintenance at 1 year) 7
• Severe degenerative changes or instability associated with radiculopathy 1, 7
• Recurrent disc herniations (92% improvement rate) 7

Note that return to work is faster with discectomy alone (12 weeks) compared to fusion (25 weeks) 7.

Key Clinical Pitfalls to Avoid

• Do not perform premature surgical intervention as initial management unless red flags are present 1
• Do not order imaging before completing conservative therapy unless red flags exist 1
• Do not add fusion during routine discectomy for isolated disc herniation—there is no benefit and it increases complications 1, 3
• Do not assume imaging findings correlate with symptoms—disc abnormalities are common in asymptomatic individuals 1
• Do not delay surgical consultation for cauda equina syndrome—this can result in permanent neurological damage 3

Prognosis

• Patients should be informed of the generally favorable prognosis, as the natural history of disc herniation is rapid resolution of symptoms within 4-6 weeks 1, 4
• Meta-analyses show similar long-term outcomes between surgical and non-surgical treatment, highlighting the importance of appropriate patient selection 1