Conservative Management of Prolapsed Intervertebral Disc (PIVD)
Conservative management with activity modification, NSAIDs, and early mobilization is the first-line treatment for PIVD, with most patients showing gradual improvement over 2-12 weeks without surgical intervention. 1, 2
Initial Management (First 2 Weeks)
Limit bed rest to less than 2 weeks to prevent complications including bone mass loss, muscle strength deterioration, deep venous thrombosis, and cardiovascular/respiratory deconditioning. 1
Pain Management
- Start NSAIDs as first-line analgesic therapy for all patients with PIVD. 1
- Add carefully monitored narcotic medications only for breakthrough pain unresponsive to NSAIDs. 1
- Avoid routine use of vestibular suppressants or benzodiazepines as they provide no benefit for mechanical back pain. 1
Activity Modification
- Patients should remain as active as tolerated within pain limits rather than complete rest. 1, 2
- Apply thoracolumbosacral orthosis (TLSO) or Jewett brace to provide stability and reduce pain during initial healing. 1
Rehabilitation Phase (Weeks 2-12)
Progressive Mobilization
- Initiate early mobilization as soon as pain permits to prevent deconditioning. 1
- Core strengthening exercises should focus on lumbar stabilization. 1
- Provide proper body mechanics training to prevent recurrence. 1
- Guide gradual return to activities based on symptom response. 1
Physiotherapy Interventions
- Physiotherapy interventions significantly reduce pain (mean difference -0.91) and disability (mean difference -5.76) in lumbar PIVD management. 3
- Mechanisms include correction of displaced disc, opening of foramina, increase in intervertebral space, and reduction in herniation size with negative intradiscal pressure. 3
Long-Term Management (Beyond 3 Months)
Ongoing Rehabilitation
- Continue progressive strengthening program to restore full function. 1
- Implement vitamin D supplementation and adequate calcium intake. 1
- Consider antiresorptive agents if underlying osteoporosis is present. 1
- Provide patient education on activity modification and proper lifting mechanics. 1
Critical Monitoring Points
Reassess patients within 1 month to document symptom resolution or persistence. 1
Red Flags Requiring Immediate Evaluation
- Cauda equina syndrome (bowel or bladder dysfunction) is an immediate surgical emergency. 1
- Progressive neurological deficits require immediate evaluation. 1
- Severe or progressive motor weakness requires immediate evaluation. 1
- Sudden increase in pain may indicate new fracture. 1
Surgical Indications
Reserve surgical intervention for patients who fail 3 months of conservative management or develop specific high-risk features. 1, 2
Absolute Indications
- Cauda equina syndrome (immediate surgery). 1
- Progressive neurological deficits. 1, 2
- Spinal instability. 1, 2
- Significant spinal deformity (≥15% kyphosis, ≥10% scoliosis, ≥20% vertebral body height loss). 1, 2
Relative Indications
Important Pitfalls to Avoid
Avoid routine imaging in uncomplicated PIVD without red flags, as numerous studies show no clinical benefit and can lead to increased healthcare utilization. 1, 2
- Do not rush to imaging or intervention in the absence of red flags. 2
- Do not perform vertebral augmentation procedures for vacuum discs in the absence of vertebral compression fractures. 2
- Ensure adequate trial of conservative therapy (minimum 3 months) before considering surgical options. 1, 2
Expected Outcomes
Most cases show gradual improvement in pain over 2-12 weeks without intervention. 2
- Conservative treatments can diminish or resolve clinical symptoms within a few weeks. 4
- Disc reabsorption has been documented with conservative management including traditional Chinese medicine, acupuncture, and massage over 12 months. 4
- Overall, 90% of patients achieve good to excellent results with appropriate conservative management. 5