What is the recommended treatment for a patient with a herniated intervertebral disc (slipped disc)?

Treatment for Herniated Lumbar Disc (Slipped Disc)

Conservative management with physical therapy and activity modification should be the initial treatment for at least 6 weeks to 6 months for all patients with herniated lumbar discs, unless red flag symptoms indicating cauda equina syndrome or progressive neurological deficits are present. 1, 2

Immediate Assessment for Red Flags

Before initiating any treatment, evaluate for emergent conditions requiring urgent surgical intervention:

• Urinary retention (90% sensitivity for cauda equina syndrome) requires emergency surgery within 48 hours to prevent permanent neurological damage 1, 2, 3
• Progressive motor weakness or foot drop requires urgent surgical consultation 2, 4
• Saddle anesthesia requires urgent surgical consultation 2, 4
• Bowel incontinence requires urgent surgical consultation 2, 4

If any of these red flags are present, obtain immediate MRI and surgical consultation. 1, 2

Initial Conservative Management (First 6 Weeks to 6 Months)

For patients without red flags, conservative therapy is the cornerstone of initial treatment:

• Advise patients to remain active rather than bed rest, which is more effective for acute radiculopathy 1, 2, 5
• Initiate physical therapy immediately focusing on core strengthening and flexibility exercises 2, 3, 6
• Provide patient education about the favorable prognosis—most patients improve within the first 4 weeks, with the natural history favoring spontaneous resolution 1, 2, 7
• Prescribe NSAIDs for pain management 7, 6
• Consider McKenzie method, mobilization, manipulation, and neural mobilization, which have moderate evidence (Level B) for effectiveness 6
• Limit muscle relaxants and narcotic analgesics to strictly time-limited use due to their limited role 7

The evidence is particularly strong for conservative management: more than 90% of symptomatic lumbar disc herniations occur at L4-5 or L5-S1 levels and resolve with conservative therapy, with only 5-10% requiring surgery. 2, 7 Sequestrated disc herniations have the highest likelihood of spontaneous regression compared to other subtypes. 3

Imaging Recommendations

Do not order routine MRI or CT initially—early imaging does not improve outcomes and can lead to unnecessary surgical intervention when findings don't correlate with symptoms. 1, 2, 4

Order MRI (preferred) or CT only when:

• Symptoms persist after 4-6 weeks of conservative management AND the patient is a potential surgical candidate 1, 2, 3
• Red flag symptoms are present requiring urgent evaluation 1, 2

The straight-leg raise test (91% sensitivity, 26% specificity) and crossed straight-leg raise test (29% sensitivity, 88% specificity) can help guide clinical decision-making without imaging. 2

Surgical Indications

Surgery should be considered only after at least 6 weeks (preferably 2-6 months) of failed conservative therapy, except in emergencies: 1, 2, 7

Absolute indications for urgent surgery:

• Cauda equina syndrome 1, 2, 3
• Progressive neurological deficits 2, 3, 4

Relative indications for elective surgery after conservative trial:

• Definite disc herniation on imaging that correlates with clinical symptoms 1, 7
• Corresponding syndrome of sciatic pain with neurologic deficit 7
• Failure to respond to 6 weeks to 6 months of conservative therapy 1, 2, 7
• Severe disabling pain refractory to conservative management 2

Surgical Approach When Indicated

Simple discectomy without fusion is the appropriate surgical procedure for isolated disc herniation causing radiculopathy. 2, 3, 4

Do not routinely add lumbar fusion to primary discectomy—there is Level III and IV evidence showing no benefit, and fusion increases surgical complexity, prolongs recovery, and increases complication rates without improving outcomes. 2, 3, 4

Fusion should only be considered in specific circumstances:

• Significant chronic axial back pain (not just radicular symptoms) 2, 3
• Manual labor occupations 3, 4
• Severe degenerative changes with documented instability 3, 4
• Recurrent disc herniations 3, 4

Alternative Interventions

Epidural steroid injections can provide short-term relief for persistent radicular symptoms and should only be considered after 4 weeks of conservative management in patients who are potential candidates for this intervention. 1, 5, 6

Long-Term Outcomes

Meta-analyses show similar long-term outcomes between surgical and non-surgical treatment after 2 years, emphasizing that patient preference and severity of disability should guide treatment decisions when conservative management has been adequate. 1, 5 Surgery may improve symptoms more quickly than continued conservative management, but does not change the ultimate outcome. 5

Critical Pitfalls to Avoid

• Delaying surgical consultation for urinary retention can result in permanent neurological damage 2, 4
• Ordering premature imaging without clinical indication leads to unnecessary surgical intervention when imaging findings don't correlate with symptoms 2, 4
• Performing surgery before 6 weeks of conservative therapy (unless red flags present) denies patients the opportunity for spontaneous resolution 2, 3
• Routinely adding fusion to discectomy increases cost and complications without benefit 2, 3, 4