Management for symptomatic lumbar disc herniation

Nonsurgical management for symptomatic lumbar disc herniation is generally recommended in the first 6 to 8 weeks. Management is essentially the same as for nonspecific low back pain (see Management for acute nonspecific low back pain). Patients should be given adequate explanation about the condition including its cause, lack of need for early diagnostic imaging, and the expected outcome.

Encourage patients to continue with usual activities; however, some activity modification may be necessary to avoid provoking pain. Physical treatments such as massage, acupuncture, exercise and traction are of unknown efficacy, and the safety of spinal manipulation in patients with significant radicular symptoms is uncertain.

There is low- to moderate-certainty evidence that translumbar, transsacral or transforaminal (or ‘nerve root’) epidural corticosteroid injections provide only a small and short-lived benefitOliveira, 2020.

The benefits of a short course (2 to 3 weeks) of oral corticosteroids (or a single intramuscular injection) are uncertain, but early administration may reduce pain and disability by a small to moderate degreeAbdel Shaheed, 2020 2020. Randomised placebo-controlled trials do not support the use of intradiscal corticosteroid injection as they have found either no benefit, or transient short-term pain relief onlyNguyen, 2017.

Use of chemonucleolysis of the disc with chymopapain injection is not supported—there is a risk of allergic reactions and other serious but rare adverse effects, and it is inferior to surgeryChou, 2009.

There is moderate- to high-certainty evidence for the lack of benefit of anticonvulsants (gabapentinoids and topiramate) in the treatment of lumbar radicular pain. This lack of benefit is accompanied by an increased risk of harm. These drugs should not be used for this indicationEnke, 2018.

Antidepressants are not currently recommended. Very low-certainty evidence suggests tricyclic antidepressants and selective noradrenaline reuptake inhibitors (SNRIs) may reduce pain in people with lumbar radicular pain; however, this requires confirmationFerreira, 2021.

Surgical consultation is indicated for all patients with severe or progressive neurological deficits, or for any patient if there is concern about a neurological deficit. Surgical consultation can also be considered for patients with severe persisting leg pain at 6 to 8 weeks, provided there is concordance between radiological findings and neurological signs. Surgery results in more rapid recovery in leg pain than nonoperative management; however, one-year outcomes are similar in patients who are treated without surgery, have early surgery and those who have surgery at a later time if needed. Potential harms from surgery include complications from anaesthesia, infection, and neurological damage.