What is the recommended treatment for a patient with a moderate size left paracentral disc herniation at L4-5 and a small right paracentral disc herniation at L5-S1, presenting with acute severe low back pain and difficulty mobilizing?

Initial Conservative Management is Strongly Recommended

For this patient with acute symptomatic L4-5 disc herniation causing radiculopathy, initial conservative treatment for at least 6 weeks should be pursued before considering surgical referral, as most patients improve within the first 4 weeks with noninvasive management. 1

Immediate Management Approach

First-Line Pharmacologic Treatment

• NSAIDs are the primary medication with good evidence for moderate pain relief in acute radicular pain from disc herniation 2
• Consider adding a skeletal muscle relaxant for acute low back pain, which has good evidence for short-term effectiveness 2
• Acetaminophen can be used as adjunctive therapy, though evidence shows fair (not good) efficacy 2
• A short course of oral prednisone (tapering 15-day course: 60mg x 5 days, 40mg x 5 days, 20mg x 5 days) provides modest functional improvement at 3 weeks (6.4-point greater ODI improvement vs placebo) and sustained benefit at 52 weeks (7.4-point greater improvement), though pain reduction is minimal 3

Non-Pharmacologic Interventions

• Superficial heat has good evidence for moderate benefits in acute low back pain 2
• Spinal manipulation has fair evidence for small to moderate benefits in acute presentations 2
• Exercise therapy, McKenzie method, and neural mobilization have moderate evidence (Level B) for effectiveness in lumbar disc herniation with radiculopathy 4
• Patient education and self-management strategies should be initiated immediately 4

What NOT to Do

Avoid Epidural Injections Initially

• The 2025 BMJ guideline provides a strong recommendation AGAINST epidural injection of local anesthetic, steroids, or their combination for chronic radicular spine pain 2
• The 2021 ACOEM guideline recommends against lumbar epidural injections for chronic low back pain in the absence of significant radicular symptoms 2
• While the 2021 ASIPP guideline supports fluoroscopically-guided epidural injections for disc herniation, this conflicts with more recent high-quality evidence recommending against this intervention 2

Avoid Premature Imaging-Guided Procedures

• Do not offer spinal injections for managing low back pain per 2020 NICE guidelines 2
• Radiofrequency ablation and facet joint injections are not indicated for radicular pain from disc herniation 2

Timeline for Specialist Referral

When to Refer (Non-Urgent)

• If symptoms persist beyond 6 weeks of conservative therapy despite appropriate management, consider referral to spine specialist 1
• The British Pain Society recommends specialist referral within 3 months for radicular pain that is not severe 2
• Earlier referral (within 2 weeks) is appropriate for severe radicular pain that is disabling and prevents normal daily activities 2

Red Flags Requiring Immediate Evaluation

Urgent MRI and immediate specialist consultation are required if any of the following develop: 1

• Progressive motor weakness (currently patient has difficulty mobilizing but no documented progressive neurological deficit)
• Cauda equina syndrome signs: urinary retention, fecal incontinence, saddle anesthesia 5, 6, 1
• Severe or rapidly progressive neurological deficits 1

Expected Natural History

• Most patients with lumbar disc herniation improve within the first 4 weeks with noninvasive management 1
• Conservative treatment can lead to complete regression of even large disc herniations over 4-12 months 7
• However, 46.2% of patients with disc herniation experience some degree of long-term low back pain (compared to 11.9% in general population), regardless of surgical or conservative management 8

Surgical Consideration Criteria

Surgery should only be considered after at least 6 weeks of failed conservative therapy, unless red flags are present 1. The current presentation does not meet criteria for immediate surgical intervention, as the patient has acute onset (1.5 weeks ago) without progressive neurological deficits or cauda equina syndrome 1.

Common Pitfalls to Avoid

• Do not rush to epidural steroid injections - the most recent high-quality 2025 BMJ guideline strongly recommends against this intervention for radicular pain 2
• Do not order routine MRI at primary care level for initial management - imaging is already available showing the herniation, but further imaging-guided interventions are not indicated at this stage 2
• Avoid opioids as first-line therapy; use lowest dose for shortest time if NSAIDs are insufficient 2
• Do not consider fusion surgery for isolated disc herniation - Level III/IV evidence shows worse return-to-work rates (45% with fusion vs 70% without) and no functional benefit 1