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Treatment of Lumbar disc Herniation

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Non-Surgical treatment

Unless there are neurological deficits, muscular weakness, difficulty in walking, or horse-tail syndrome, the first treatment option is conservative care with the aim of alleviating the pain.

The common non-surgical measures include:

Rest. As a general measure, one or two days of rest calm severe pain; however, the rest should not last too long. The patient should have some rest periods during the day but avoid sitting down for long periods of time. Because the associated muscle atrophy can lead to a delayed recovery of the back.

Controlling all movements and carrying them out slowly. The patient should change daily activities in order to avoid movements that cause more pain, especially bending forwards and lifting heavy objects.

Anti-inflammatory drugs. Drugs like ibuprofen or naproxen can reduce the pain.

Physical therapy. Some specific exercises can strengthen the lower back and the abdominal muscles.

Epidural steroid injection. In this procedure, steroids are injected into the back to reduce the local inflammation. Studies demonstrate that epidural injections can be successful in between 42% to 56% of patients that have not had relief with another six-weeks or longer non-surgical treatment. It should be noted that if motor symptoms, weakness, or intractable pain are present, surgical treatment should be considered from the outset.

Surgical Treatment

A small percentage of patients with lumbar disc herniation require surgery. Spinal surgery is recommended only after a period of non-surgical treatment that has failed to relieve symptoms, or if alarm symptoms appear, such as: intractable pain, motor deficits (difficulty moving the toes, foot, or extending the leg), or difficulty walking.

Lumbar Microdiscectomy
The most common surgical procedure for a lumbar disc herniation is lumbar microdiscectomy. It involves removing a small portion of the damaged disc to relieve nerve compression and create more space for the nerve to heal.

Endoscopic Surgery
In recent years, endoscopic lumbar spine surgery has become increasingly accepted as a standard treatment. It offers comparable results with minimal damage to surrounding tissues.

At Hospital Clínic, we perform endoscopic lumbar spine surgery using two available techniques: Monoportal Endoscopy and Biportal Endoscopy (BESS), evaluating each case individually.

Complications of Surgical Treatment
Only in very extreme cases and under specific criteria is vertebral stabilization required.

Surgical treatment of lumbar disc herniation generally does not affect spinal stability, except in certain cases. However, the overall impact of discectomy on spinal balance is still unclear. Some argue that discectomy may cause “vertical instability” and advocate for spinal fusion or alternative stabilization techniques. Others believe dynamic prostheses might protect the injured disc and adjacent discs from further degeneration, though this is not scientifically proven.

Approximately 25% of operated patients develop significant axial pain in the mid-term, which may eventually require surgical treatment with vertebral stabilization. Several technical refinements—such as minimal bone resection and removal of only the herniated fragment without disc clearing—are improving outcomes (Barth, Weiss, and Thomé, 2008).

A major study (Resnick et al., 2005) clearly concluded that spinal stabilization is not indicated in lumbar disc herniation except in the following cases:

Degenerative pathology – Lumbar disc herniation
Associated pre-existing instability (e.g., herniation with isthmic spondylolisthesis)
Iatrogenic instability due to surgical access (e.g., extensive or complete facetectomies)
Significant axial pain associated with radicular syndrome

Postoperative Treatment
Once surgical healing is complete, patients can begin a rehabilitation exercise program for the affected area. This is a simple home-based plan that includes 30-minute daily walks and flexibility exercises for the back and legs. If needed, the surgeon will refer the patient to a physiotherapist.