What is the initial management approach for a patient with a prolapsed intervertebral disc?

Management of Prolapsed Intervertebral Disc

Initial Conservative Management is First-Line for Most Patients

For patients with prolapsed intervertebral disc without red flag features, conservative management should be initiated immediately and continued for at least 2 months before considering surgery, as this approach yields satisfactory results in the majority of patients. 1, 2

Immediate Assessment for Red Flags

Before initiating conservative therapy, you must actively screen for cauda equina syndrome (CES) and other emergent conditions:

• Bilateral radiculopathy (bilateral radicular pain, sensory loss, or weakness) represents incomplete CES (CESI) and requires urgent MRI and potential emergency surgery to prevent progression to retention CES (CESR) 1
• New urinary symptoms including hesitancy, poor stream, urgency, or reduced bladder/urethral sensation with preserved voluntary control of micturition indicates CESI 1
• Subjective or objective perineal sensory loss with preserved bladder control is a true red flag for impending CESR 1
• Painless urinary retention with perineal anesthesia and patulous anus represents late-stage CESR where damage has already occurred 1

When to Image Urgently

Obtain immediate MRI (preferred over CT) if any of the following are present: 1

• Progressive or severe neurologic deficits
• Suspected cauda equina syndrome (any bilateral radiculopathy or new bladder symptoms)
• History of cancer with new back pain
• Suspected vertebral infection (fever, IV drug use, recent infection)
• Severe or progressive motor weakness

Do not routinely image patients with uncomplicated radiculopathy in the first 4 weeks, as natural history favors improvement with conservative management and imaging does not change outcomes 1

Conservative Treatment Protocol (First 2 Months Minimum)

Advise patients that acute disc herniation with radiculopathy improves spontaneously in most cases within the first 4 weeks 1:

• Remain active - bed rest is inferior to continued activity 1
• Analgesics and NSAIDs for pain control
• Physical therapy may be beneficial
• Reassure about favorable natural history 1

Conservative management produces satisfactory results in a high proportion of patients, particularly those with mild to moderate nerve root compression 2

Surgical Indications After Failed Conservative Management

Surgery should be considered only after at least 2 months of failed conservative treatment in patients with persistent radiculopathy who are candidates for intervention 1, 2

Optimal Surgical Candidates

Surgery yields better outcomes in patients with: 2

• Marked nerve root compression on imaging
• Minimal or no back pain (predominantly leg pain)
• Short duration of symptoms before surgery
• Correlation between clinical symptoms and MRI findings 1

Surgical Approach

Standard discectomy remains the gold standard - it provides faster symptom relief than conservative management and superior outcomes compared to chemonucleolysis 3

Microdiscectomy versus standard discectomy: Three trials showed no difference in long-term clinical outcomes, though microdiscectomy may offer slightly better results in the first few weeks to months post-operatively 3, 2

Emergency Surgical Indications

Operate emergently (within 12 hours if possible) for: 1

• CESR (retention cauda equina syndrome) within 12 hours of onset
• Any CESR patient with preserved perineal sensation and/or anal tone
• Progressive severe motor weakness

Patients treated at the CESI stage (before urinary retention develops) typically achieve normal or socially normal bladder and bowel function long-term, while those treated after CESR often require intermittent self-catheterization and have severe impairment 1

Critical Pitfalls to Avoid

• Do not catheterize patients with suspected CES before surgical assessment - this obscures whether the patient has progressed to CESR and prevents optimal surgical timing decisions 1
• Do not delay surgery in bilateral radiculopathy with new bladder symptoms - these are true red flags indicating CESI, not late-stage findings 1
• Do not perform routine MRI in uncomplicated radiculopathy within first 4 weeks - natural history favors improvement and imaging does not improve outcomes 1
• Recognize that surgical results often deteriorate long-term due to recurrence of radicular and especially low back pain, though this occurs similarly in both surgical and conservative groups 2
• Surgery provides faster relief but does not alter the lifetime natural history of the underlying disc disease 3