Lumbar herniated disc: treatment options before and after considering surgery

A lumbar herniated disc is probably the spine condition patients know best — and, paradoxically, one of the most poorly explained. A herniated-disc diagnosis often comes wrapped in alarming words and a picture of the problem in which surgery seems inevitable. The international evidence shows something very different: between 60% and 90% of herniated discs improve with conservative treatment within the first 6 to 12 months, with no need for an operation.

In my daily practice I see that most patients who arrive with an MRI showing a lumbar herniated disc believe surgery is the only path, or that an operation is inevitable in the short term. The reality is quite different: most symptomatic lumbar herniations improve with well-executed conservative treatment within six to twelve weeks, and only a minority end up needing a surgical procedure. Hearing that from the very beginning changes the patient's mindset and lets them go through treatment without that constant background anxiety.

Let me explain what a herniated disc really is, what the treatment options are in increasing order of complexity, and in which cases surgery is indeed worth considering.

What a herniated disc actually is

Between each vertebra of the spine sits an intervertebral disc, which works as a shock absorber. Every disc has two parts: a gel-like central core (the nucleus pulposus) and an outer fibrous ring that contains it. A herniation occurs when that fibrous ring weakens or tears at one point and the core pushes outward, compressing neighboring structures — usually a nerve root exiting the spine.

One thing is important to understand: having a herniated disc on an MRI does not automatically mean having symptoms. Plenty of people have herniations visible on imaging and have never had any pain. The image looks worse than it feels: what actually causes pain is the inflammation, the nerve compression and the mechanisms associated with them. That is why treatment decisions are not based on the imaging alone, but on the patient's clinical picture.

A nuance I repeat constantly in my office: finding a herniated disc on an MRI is not the same as having a symptomatic herniated disc. It is well documented that a substantial share of people over 40 with no pain at all have disc herniations or protrusions visible on imaging. So when a patient brings me an MRI labeled "L4-L5 herniation", the first thing I do is check whether their pain and neurological symptoms actually match the nerve root that herniation should be compressing. If there is no clinical correlation, that herniation is probably not what is causing the problem.

Typical symptoms

A lumbar herniated disc typically produces:

• Low back pain that radiates down one leg (sciatica), following the path of the affected nerve.
• Tingling, numbness or a burning sensation in the leg, usually in a specific area.
• Worsening after prolonged sitting, when coughing, sneezing or straining during bowel movements (all situations that increase pressure inside the disc).
• Sometimes muscle weakness in the affected leg: difficulty standing on tiptoe or lifting the foot, or a feeling that the leg "gives way".

Treatment options, step by step

Step 1 — Initial medical treatment

In the first weeks, the goal is to control pain and inflammation. This includes:

• Relative rest (not complete rest: prolonged inactivity makes the condition worse).
• Anti-inflammatories and analgesics on a scheduled regimen, not "as needed".
• In some cases, short courses of oral corticosteroids.
• Muscle relaxants for reactive muscle spasm.
• Specific medications for neuropathic pain when the pain radiates down the leg (gabapentin, pregabalin, low-dose antidepressants).

Step 2 — Targeted physical therapy

Once the acute pain subsides, physical therapy focused on core strengthening, postural re-education and decompression techniques is essential. Not just any exercise will do: physical therapy has to be specific to the condition and guided by a professional experienced in treating low back pain.

Step 3 — Lumbar epidural injection

When pain persists or is very intense, epidural injections guided by fluoroscopy or ultrasound are a very useful option. They involve placing corticosteroids and local anesthetic near the inflamed nerve root, delivering the medication directly to the site of the problem. The procedure takes 20-30 minutes, is done on an outpatient basis, and results are usually seen within the first two to four weeks.

The evidence shows that epidural injections are particularly effective for radicular pain (the leg pain caused by nerve root compression), with significant improvement rates in carefully selected patients.

Step 4 — Other interventional techniques

In specific cases, other options may be considered:

• Pulsed radiofrequency of the dorsal root ganglion: a minimally invasive technique that modulates pain transmission.
• Epidural adhesiolysis: indicated in some cases with post-surgical fibrosis.
• Selective nerve root blocks: both diagnostic and therapeutic.

Step 5 — Surgery

Today, surgery is reserved for specific situations:

• Progressive neurological deficit (muscle weakness that keeps getting worse).
• Cauda equina syndrome: loss of bladder or bowel control, saddle anesthesia. This is a surgical emergency.
• Disabling pain that does not respond to properly conducted conservative treatment over 8 to 12 weeks.

A different perspective on surgery

If surgery has been suggested and you have doubts, a second opinion from a Pain Medicine specialist can add real value. Not because surgery is the wrong call in every case: sometimes it is the best option and it is better done sooner rather than later. But there is a whole group of patients who receive that recommendation without having exhausted the interventional alternatives — and who do very well with less invasive treatments.

My general recommendation is that, for a herniated disc without serious neurological symptoms, you try at least 8 to 12 weeks of properly conducted conservative treatment — including appropriate medication, targeted physical therapy and at least one attempt at an epidural injection if the pain warrants it — before making the surgical decision.

My criterion for recommending an epidural or selective nerve root block is not the image, but the clinical course and the functional impact. I reserve interventional procedures for patients with well-defined radicular pain that has not eased after four to six weeks of adequate conservative treatment, or who have significant functional impairment from the start. Doing injections too early, when the condition still has a good chance of improving on its own, is overtreatment; doing them too late, when the radiculopathy has been established for months, tends to give worse results. The window of opportunity matters — a lot.

The patient's role

A herniated disc is not something that gets "cured" passively. Recovery depends heavily on:

• Following the medical treatment exactly as prescribed.
• Keeping up physical therapy beyond the initial relief.
• Changing habits that load the spine (a sedentary lifestyle, posture, body weight).
• Maintaining gentle aerobic activity: walking, swimming, stationary cycling.

The good news is that, with a comprehensive, well-executed approach, most patients with a herniated disc get back to their normal lives without needing surgery.

To me, a successful herniated-disc treatment is not the one that makes the pain vanish in a week, but the one that gives patients their lives back without fear of movement. There is a phenomenon I see all the time: patients who no longer have pain but still live as if they were fragile, because they are terrified that a disc might "slip out". That is why, at every follow-up visit, I take time to explain what you CAN do and why moving is part of the treatment. A patient who understands their condition is a patient who does not relapse.

Dr. Mauricio Casarsa

Anesthesiologist, specialist in Pain Medicine and Interventional Pain Management. Postgraduate training at UBA (Fundación Dolor) and UNLP (CAIDBA). Staff physician at Hospital Alemán, Buenos Aires.

MN 137756 · San Isidro · Villa Urquiza