How to alleviate pain associated with herniated discs and syrinx of the back?

Pain Management for Herniated Discs and Syrinx

For herniated disc pain, start with conservative management including NSAIDs, activity modification, and physical therapy for at least 4-6 weeks before considering any interventional procedures, and reserve epidural steroid injections only for persistent radicular pain after conservative therapy fails. 1, 2 Note that syrinx (syringomyelia) is a distinct spinal cord pathology requiring neurosurgical evaluation and is not addressed by herniated disc treatment guidelines.

Initial Conservative Management (First 4-6 Weeks)

Start immediately with these evidence-based interventions:

• NSAIDs provide significant improvement in acute low back and sciatic pain caused by disc herniation and should be your first-line pharmacologic intervention 3

• Advise patients to remain active rather than prescribing bed rest, as activity is more effective than rest for acute or subacute low back pain 1, 2

• Initiate physical therapy immediately focusing on core strengthening, flexibility exercises, and the McKenzie method 2, 4, 5

• Provide patient education about the favorable prognosis—most lumbar disc herniations with radiculopathy improve within the first 4 weeks with noninvasive management 1, 2, 6

• Activity modification combined with pharmacotherapy and physical therapy provides good outcomes in most herniated disc patients 3

When Conservative Management Fails (After 4-6 Weeks)

If radicular pain persists despite adequate conservative therapy:

• Epidural steroid injections (interlaminar, transforaminal, or caudal) with local anesthetic, steroids, or their combination have strong evidence for disc herniation with radicular symptoms 1

• The 2021 American Society of Interventional Pain Physicians guidelines provide strong recommendations for fluoroscopically guided epidural injections for chronic spine pain associated with disc herniation 1

• However, the 2020 NICE guidelines recommend against spinal injections for managing low back pain without significant radicular symptoms 1

Critical distinction: Epidural injections are appropriate for radicular pain (leg pain following nerve distribution), but the 2025 BMJ guidelines strongly recommend AGAINST epidural injections for chronic axial spine pain (back pain alone) 1

Red Flags Requiring Urgent Evaluation

Evaluate immediately for these emergencies:

• Urinary retention has 90% sensitivity for cauda equina syndrome and requires emergency surgical intervention 1, 2, 6

• Progressive motor weakness, saddle anesthesia, or bowel incontinence warrant urgent MRI and neurosurgical consultation 2, 6

• Delaying surgical consultation for cauda equina syndrome results in permanent neurological damage 2, 6

Imaging Considerations

Do not order imaging prematurely:

• MRI or CT should only be obtained if patients are potential candidates for surgery or epidural steroid injection after failed conservative therapy 1, 2

• Routine imaging does not improve outcomes and should be avoided in the first 4-6 weeks unless red flags are present 1, 2, 6

• Imaging findings must correlate with clinical symptoms—disc abnormalities are common in asymptomatic individuals, and over-reliance on imaging without clinical correlation leads to unnecessary interventions 2, 6

Surgical Considerations (After 6 Months of Conservative Therapy)

Surgery should only be considered when:

• At least 6 months of comprehensive conservative therapy has failed, including structured exercise, physical therapy, and optimized pharmacologic management 4, 3

• Progressive neurological deficits are present 2, 6

• Cauda equina syndrome develops 2, 6, 3

Critical surgical pitfall to avoid:

• Lumbar spinal fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy 1, 2, 6

• Fusion only increases complexity, surgical time, and complications without improving outcomes in routine disc herniation 1, 6

• Fusion may be considered only in specific circumstances: significant chronic axial back pain, manual labor occupations, severe degenerative changes with instability, or recurrent disc herniations 1, 2, 6

Interventional Procedures to AVOID

The 2025 BMJ guidelines provide strong recommendations AGAINST these procedures for chronic axial spine pain:

• Joint radiofrequency ablation with or without joint-targeted injection 1

• Joint-targeted injections of local anesthetic, steroids, or their combination 1

• Intramuscular trigger point injections of local anesthetic with or without steroids 1

• Dorsal root ganglion radiofrequency for chronic radicular spine pain 1

These recommendations conflict with the 2022 American Society of Pain and Neuroscience guidelines, which provide strong recommendations IN FAVOR of these procedures 1. Given this contradiction, prioritize the more recent 2025 BMJ guidelines that recommend against these interventions for axial spine pain.

Special Consideration: Syrinx

Syrinx (syringomyelia) is a completely different pathology involving fluid-filled cavities within the spinal cord and requires:

• Neurosurgical evaluation to determine the underlying cause (Chiari malformation, spinal cord tumor, trauma, arachnoiditis)

• Treatment directed at the underlying cause, which may include surgical decompression, shunting, or tumor resection

• Pain management for syrinx is not addressed in herniated disc guidelines and requires specialized neurosurgical consultation

Common Pitfalls to Avoid

• Do not perform premature surgical intervention as initial management unless red flags are present 2, 6

• Do not order imaging before completing a trial of conservative therapy unless red flags exist 2, 6

• Do not add fusion during routine discectomy for isolated disc herniation 1, 2, 6

• Do not assume imaging findings correlate with symptoms—clinical correlation is essential 2, 6

• Do not offer interventional procedures for axial back pain alone without radicular symptoms 1