Herniated disc treatment: options and decision-making challenges

Medical treatment: the first line of defense

Conservative medical treatment is the standard first-line approach. It relies on several components, the combination of which varies according to the intensity of symptoms and the patient's profile.

The medications usually prescribed belong to several classes: appropriate-level analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and in some cases, short courses of oral corticosteroids. Physical therapy is often prescribed as a supplement: it aims to relieve pain, maintain mobility, and strengthen the muscles that support the spine. It is generally not started during the intense acute phase.

Brief rest is recommended: prolonged bed rest is not a treatment and can worsen functional outcomes. An evaluation period of 4 to 6 weeks is usually observed before considering a step up in treatment.

{{encart-vert}}

‍

Injections: a key intermediate step

When medical treatment is not enough to control pain, corticosteroid injections represent the next step before considering surgery.

An epidural injection involves injecting a corticosteroid into the area around the compressed nerve roots, under radiological guidance. The goal is to reduce local inflammation and relieve compression. Results vary by patient: some see significant improvement after one or two injections, while others experience a partial or temporary response. If partially effective, two or three injections may be performed within a set timeframe.

When injections have not yielded the expected results, the patient may face legitimate doubt: is it a technical issue, a localization problem, or is surgery inevitable? A review of the case by a spine specialist can shed light on the remaining options and the appropriateness of the protocol followed.

{{encart-orange}}

{{cta03-large}}

‍

Surgery: understanding the options and when they are indicated

Surgery is considered when conservative treatment—such as medication and injections—has not provided sufficient improvement after several weeks, or in the event of a neurological emergency.

When surgery is indicated

• Failure of well-managed medical treatment after 6 to 12 weeks of debilitating pain.
• Significant or rapidly worsening motor deficit (muscle weakness, foot drop).
• Cauda equina syndrome: loss of bladder or bowel control, numbness in the perineal area—an absolute surgical emergency.
• Intolerable pain that is resistant to all conservative treatments.

The two surgical techniques

In both cases, the procedure involves removing the disc fragment that is compressing the nerve (partial discectomy). The two current approaches are:

• Microscopic discectomy (microsurgery): access via a small incision, with the surgical field visualized under a microscope. This has been the gold-standard technique for several decades, with extensive clinical follow-up. ‍
• Endoscopic discectomy: access via a few-millimeter trocar using an endoscopic camera. Less invasive than open surgery, with a potentially faster return to daily activities for some patients.

The available data does not establish the general superiority of one technique over the other. The choice depends on the anatomical configuration of the hernia, the surgeon's experience with each technique, and the patient's clinical context.

{{encart-bleu}}

‍

Herniated disc associated with underlying spinal pathology

When a herniated disc occurs in a spine with associated pathology (lumbar canal stenosis, spondylolisthesis, degenerative scoliosis), treating only the hernia may prove insufficient. Identifying this underlying condition directly influences the type of surgery and its expected outcomes.

{{cta01-large}}

‍