What is the recommended treatment for a 2mm disc protrusion with a central annular fissure?

Treatment of 2mm Disc Protrusion with Central Annular Fissure

Conservative management with physical therapy and medical management is the recommended first-line treatment for a 2mm disc protrusion with central annular fissure, as imaging abnormalities like disc protrusions and annular fissures are extremely common in asymptomatic patients and most cases respond to non-operative treatment. 1

Initial Management Approach

Do Not Rush to Intervention

• Disc protrusions and annular fissures are frequently found in asymptomatic individuals, with disc protrusion prevalence ranging from 29% in 20-year-olds to 43% in 80-year-olds who have no back pain 1
• A 2mm protrusion is considered minimal and falls well within the range of incidental findings that require no specific treatment 1
• 84% of patients with lumbar imaging abnormalities before symptom onset showed unchanged or improved findings after symptoms developed, indicating that the imaging finding may not be the cause of symptoms 1

Conservative Treatment Protocol

Start with a structured 6-8 week conservative management program that includes:

• Physical therapy focusing on core stabilization exercises, which has moderate evidence showing superiority over no treatment 2
• NSAIDs or acetaminophen for pain control as needed 2
• Activity modification without complete bed rest 1
• Patient education emphasizing the benign natural history of disc protrusions 1

When to Consider Advanced Treatment

Timing Considerations

• Wait at least 6-8 weeks before considering any interventional or surgical options, as the majority of disc herniations show some degree of reabsorption or regression by 8 weeks after symptom onset 1
• Early imaging and intervention are associated with increased healthcare utilization without improved outcomes 1

Indications for Surgical Consideration

Surgery should only be considered if:

• Conservative management fails after at least 6 months of appropriate treatment 3
• Progressive neurological deficit develops (not just pain) 3
• Cauda equina syndrome occurs (immediate surgical emergency) 1

If surgery becomes necessary after failed conservative care, outcomes are generally favorable, with 86% achieving good results at long-term follow-up for central disc protrusions 3

Critical Pitfalls to Avoid

• Do not perform repeat imaging for new episodes of low back pain if previous MRI exists, as repeat scans are unlikely to detect meaningful differences in disc protrusion or annular fissures 1
• Avoid early surgical referral, as patients who receive early imaging and intervention have increased likelihood of injections, surgery, and disability compensation without better outcomes 1
• Do not assume the imaging finding is the pain generator, as the correlation between imaging abnormalities and symptoms is poor 1

Expected Natural History

• Most cases of acute low back pain with or without radiculopathy are self-limiting conditions responsive to medical management and physical therapy 1
• The presence of a small disc protrusion with annular fissure does not change this favorable prognosis 1
• Pain is likely mediated by inflammatory neuropeptides and arachidonic acid products from mechanical annular injury, which typically resolve with time 3