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Care guidelines: Managing acute disc herniations

Based on your history and physical exam of a patient, you have made a tentative diagnosis of acute herniated disc. 

A. If you suspect a progressive neurologic deficit, cauda equina syndrome or myelopathy 
based on your exam and/or you obtain a history of bowel/bladder retention or incontinence, an IMMEDIATE surgical referral is indicated.

B. For all other patients with suspected herniated nucleus putposus (HNP) who have a static or no neurologic deficit, here are treatment strategies to employ.

• Educate the patient.
  - Tell him or her your findings from the history and physical and explain the suspected pathophysiology. 
  
  - Ideally, use a model of the spine with nerve roots to explain the anatomy. It is important to explain what each nerve root does to be able to discuss imaging issues later. You will need to know the motor, sensory, and reflex functions or L4, L5, S1, C4, C5, C6 and C7. (Click here to link to nerve root syndrome illustrations).
  
  - Share educational articles about “disappearing disc herniations” and “good outcomes for HNPs with conservative care.”  See articles at the Physicians Neck and Back Clinic web site,  www.pnbconline.com.
  
  - Tell him or her how to watch for signs of clinical status deterioration: bowel/bladder changes, foot weakness, foot drop. 
  
  - Describe what the normal followup is for HNP cases. Mention that the disc may never look normal on an image test again, but it can heal with full function. Many pro athletes have had HNPs with or without surgery and are totally functional.
  
  
• Reassure the patient.
  - Tell him or her that most HNPs resolve without the need for surgery or imaging tests. 
  
  - If needed, remind him or her of the significance of neurological deficits being either static or absent.
  
  
• Discuss your guidelines for further evaluation.
  - Indications for surgery/imaging tests:
  • progressive neurologic deficits
  • intractable leg pain (not back pain)
  Your goal is help your patient avoid immediately considering surgery as the only or best treatment available. If the treatment plan does not help, your patient will be scheduled for imaging tests and referred if necessary.
  
  - Imaging tests will be scheduled only if you and your patient would agree that surgery is needed. 
  • Imaging tests will confirm your diagnosis and identify the anatomy for the surgeon. 
  • You may want to discuss with the surgeon and radiologist which imaging tests to order.
  
  
• Control the pain.
  - Use whatever will be effective, including Medrol (or equivalent) dose packs.
  
  - If you prescribe narcotics, use short-term only and state the time frame.
  
  - Explain that epidural injections may be an option to control pain if other treatments don’t work. 
  
  
• Schedule a PT consult if needed. Choose a PT who is well-versed in McKenzie evaluations.
  
  
• Avoid passive treatments. They have never been shown to impact the course of HNPs.
  
  
• Develop an activity plan that balances healing with mobility to keep the spine/disc functional.
  - Short-term bed rest may be indicated, but long-term bed rest is debilitating. Decreased activity will slow down the diffusion of nutrients to discs when they need it the most for repair.
  
  - Activity that causes some pain is okay, as long as it doesn’t increase leg pain. Your patient should avoid posture or activities that increase intradiscal pressure: prolonged sitting, heavy lifting, coughing, etc.
  
  - Gradually increase activities as your patient improves.
  
  - It may take six to eight weeks for your patient to get back to full, unrestricted heavy activities. 
  
  - BEFORE you suggest or imply that you are considering imaging tests or a surgical referral, obtain a consult from an intensive spine rehabilitation clinic such as the Physicians Neck and Back Clinic.
  
  
• As your patient improves, taper medicines and increase activity levels. 
  
  
• Educate yourself – an important part of your treatment strategy.
  - Read articles on HNP. If you project knowledge and confidence when discussing plans and options with your patients, most will work with you. Your demeanor and approach on the initial visit will determine your success.
  
  - If you are nervous with neurologic deficits, don’t control the pain or don’t educate your patient well enough, he or she may demand imaging tests and a referral to a specialist.
  
  - If you are not comfortable managing acute HNPs, ask one of your partners to get involved. 
  

First published: 03/05/2002
Last updated: 06/01/2002

Reviewed by: Paul Kleeberg, MD