From the Guidelines
For a large central disc extrusion, clinicians should prioritize non-invasive management, including rest, pain management with NSAIDs, and physical therapy, before considering invasive interventions like surgery or epidural steroid injection, as the natural history of lumbar disc herniation with radiculopathy often shows improvement within the first 4 weeks with conservative treatment 1.
Initial Management
Treatment for a large central disc extrusion typically begins with conservative management to alleviate symptoms and promote recovery. This includes:
- Rest for 24-48 hours to reduce inflammation and stress on the spine
- Pain management using NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks
- Muscle relaxants like cyclobenzaprine (5-10mg three times daily) for muscle spasms
- Application of ice for the first 48-72 hours (20 minutes on, 40 minutes off), then switching to heat therapy to help manage pain and inflammation
Diagnostic Imaging
According to the guideline from the American College of Physicians and the American Pain Society 1, MRI (preferred) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions, as these imaging modalities can better visualize the spinal canal and soft tissues, aiding in the diagnosis of conditions like spinal stenosis or disc herniation.
Physical Therapy and Rehabilitation
Physical therapy focusing on core strengthening and proper body mechanics should begin after acute pain subsides, usually within 2-4 weeks. This helps in stabilizing the spine, improving posture, and preventing future injuries.
Invasive Interventions
If symptoms persist or include severe neurological deficits like leg weakness, numbness, or bladder/bowel dysfunction, surgical intervention or epidural steroid injection may be necessary. The decision for such interventions should be made on a case-by-case basis, considering the patient's overall health, the severity of symptoms, and the potential benefits and risks of the procedure, as suggested by the guideline 1.