What is the physiotherapy protocol for a sequestrated disc?

Physiotherapy Protocol for Sequestrated Disc

For sequestrated disc herniation, physical therapy focusing on core strengthening and flexibility exercises should be the cornerstone of initial conservative management for at least 6-8 weeks (or 2 months minimum), as patients have a high likelihood of spontaneous regression with symptomatic resolution typically occurring within 1-2 months. 1, 2

Initial Conservative Management Approach

• Patients must remain active rather than rest in bed, as activity modification is significantly more effective than bed rest for acute radiculopathy from sequestrated discs 1
• Conservative treatment should continue for at least 2 months before considering any surgical intervention, since most sequestrated disc herniations improve within the first 4 weeks 1, 2
• Physical therapy should emphasize core strengthening and flexibility exercises as the primary treatment modality 3, 1

Expected Timeline for Recovery

• Symptomatic resolution occurs in a mean of 1.33 months (approximately 4-6 weeks) with conservative management 4
• Radiographic resolution of the sequestration takes longer, averaging 9.27 months, but clinical improvement precedes imaging changes 4
• Sequestrated discs have the highest likelihood to spontaneously regress compared to other disc herniation subtypes, likely due to inflammatory-mediated resorption of the free fragment 4, 2

Red Flags Requiring Immediate Surgical Referral (Not Physiotherapy)

Critical pitfall to avoid: Do not continue conservative physiotherapy if any of these red flags develop:

• Urinary retention (90% sensitivity for cauda equina syndrome) requires immediate surgical consultation 1
• Progressive motor weakness, including foot drop or extremity weakness 1
• Saddle anesthesia or bowel incontinence 1
• Inability to walk or intractable pain despite conservative measures 4

Physiotherapy Protocol Specifics

Core Strengthening Components

• Focus on lumbar stabilization exercises targeting transversus abdominis and multifidus muscles 3, 1
• Progressive resistance training for paraspinal musculature 3

Flexibility Components

• Hamstring stretching to reduce neural tension 3
• Hip flexor stretching to improve lumbar mechanics 3
• Gentle lumbar range of motion exercises as tolerated 3

When Imaging Is Indicated

• Do not obtain routine MRI initially, as routine imaging does not improve outcomes and can lead to unnecessary interventions 1
• MRI is indicated only after 4-6 weeks of persistent symptoms in patients who are potential candidates for epidural steroid injection or surgery 1
• Imaging findings must correlate with clinical symptoms to guide treatment decisions 1

Progression Beyond Conservative Management

If symptoms persist after 2 months of appropriate physiotherapy:

• Epidural steroid injections are the next treatment option for persistent radicular symptoms 1
• Simple discectomy without fusion is appropriate if surgery becomes necessary after failed conservative management 1
• Fusion is NOT routinely recommended for isolated sequestrated discs and should only be considered in specific circumstances: significant chronic axial back pain, manual laborers with axial pain plus radiculopathy, or documented preoperative instability 1

Important Clinical Considerations

• Sequestrated discs regress through dehydration and inflammation-mediated resorption due to their higher water content 2
• The inflammatory response against the free fragment is the most likely mechanism for spontaneous regression 4
• Conservative management success rates are high, with patients recovering from radicular pain within 3-6 weeks in documented case series 2