What is the treatment for pain associated with a herniated lumbar disc?

Treatment of Pain Associated with Herniated Lumbar Disc

Conservative management with activity modification and physical therapy should be the initial treatment for all patients with herniated lumbar disc pain, unless red flags such as urinary retention, progressive motor weakness, or cauda equina syndrome are present. 1, 2

Initial Management Approach

Patient Education and Activity Modification

• Inform patients of the favorable prognosis—more than 90% of symptomatic lumbar disc herniations improve within the first 4 weeks with noninvasive management 1, 2
• Advise patients to remain active rather than bed rest, as staying active is more effective for acute or subacute low back pain 1, 2
• Explain that early imaging does not improve outcomes and most patients experience substantial improvement within the first month 1

Pharmacologic Management

• NSAIDs are first-line medication: Ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg daily), taken with meals or milk to minimize gastrointestinal complaints 3
• Doses greater than 400 mg every 4-6 hours provide no additional analgesic benefit for acute pain 3
• Use the lowest effective dose for the shortest duration 3

Physical Therapy

• Core strengthening and flexibility exercises are cornerstones of treatment 2
• Physical therapy should be initiated early in the treatment course 2
• A recent 2025 randomized controlled trial of 424 participants demonstrated that lumbar traction combined with medical treatment is superior to medical treatment alone, with 62% achieving ≥25% pain reduction versus 51% with medical treatment alone (p=0.024) 4

When to Obtain Imaging

Do not order MRI or CT initially—routine imaging does not improve outcomes and should be reserved for specific indications 1, 2

Imaging Indications:

• Persistent symptoms after 4-6 weeks of conservative management in patients who are potential candidates for surgery or epidural steroid injection 1, 2
• Presence of red flags requiring urgent evaluation 2
• MRI is preferred over CT as it provides better visualization of soft tissue, vertebral marrow, and spinal canal without ionizing radiation 1

Red Flags Requiring Urgent Evaluation

Immediate MRI and surgical consultation are mandatory when any of the following are present 2:

• Urinary retention (90% sensitivity for cauda equina syndrome) 2
• Bowel incontinence 2
• Progressive motor weakness 2
• Saddle anesthesia 2
• History of cancer with new back pain 2

Delaying surgical consultation for cauda equina syndrome can result in permanent neurological damage 2, 5

Interventional Procedures

Epidural Steroid Injections

The evidence on epidural injections is contradictory across guidelines:

Supporting evidence:

• The 2022 American Society of Pain and Neuroscience provides a strong recommendation in favor of epidural injections (interlaminar, transforaminal, or caudal) of local anesthetic, steroids, or their combination for chronic low back pain due to disc disease 1
• The 2021 American Society of Interventional Pain Physicians recommends fluoroscopically guided epidural injections with or without steroids for disc herniation (strong recommendation) 1
• Epidural steroid injections can provide short-term relief 6

Opposing evidence:

• The 2021 American College of Occupational and Environmental Medicine recommends against lumbar epidural injections for chronic low back pain in the absence of significant radicular symptoms 1
• The 2020 NICE Guideline states: do not offer spinal injections for managing low back pain 1

Clinical interpretation: Epidural steroid injections may be considered for patients with radicular symptoms (leg pain in nerve root distribution) who have failed 4-6 weeks of conservative management and are not yet candidates for surgery 1

Procedures NOT Recommended

The 2025 BMJ guideline provides strong recommendations AGAINST the following for chronic radicular spine pain 1:

• Dorsal root ganglion radiofrequency with or without epidural injection
• These interventions should not be offered outside of clinical trials 1

Surgical Considerations

Indications for Surgery

Surgery should be considered only when 2, 5:

• Cauda equina syndrome is present (emergency) 2
• Progressive neurological deficits develop 2, 5
• Severe disabling pain refractory to 6 months of conservative therapy 2

Surgical Outcomes

• There is no difference in outcomes between surgical and conservative treatment after 2 years 6
• If disc herniation correlates with physical findings, surgical discectomy may improve symptoms more quickly than continued conservative management 6
• Simple discectomy without fusion is sufficient for isolated disc herniation—fusion is NOT routinely indicated and increases complexity and complications without improving outcomes 2, 5

Timeline for Conservative Management

Maintain conservative management for at least 6 months unless red flags develop 2:

• Most patients improve within the first 4 weeks 1, 2
• Reassess at 4-6 weeks to determine if imaging or interventional procedures are needed 1, 2
• Continue conservative management up to 6 months before considering surgery for refractory pain 2

Critical Pitfalls to Avoid

• Never delay evaluation for cauda equina syndrome—urinary retention has 90% sensitivity and requires emergency intervention 2, 5
• Do not order routine imaging in the first 4 weeks unless red flags are present—imaging does not improve outcomes and leads to unnecessary interventions 1, 2
• Do not recommend bed rest—advise patients to remain active 1, 2
• Avoid premature surgical intervention—surgery is not indicated as initial management unless red flags are present 2
• Do not add fusion to routine discectomy for isolated disc herniation—this increases complications without benefit 2, 5