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Nonsurgical treatments for herniated disk
By Mayo Clinic staffMost herniated disk problems improve with nonsurgical treatment. The goal of such conservative treatment is to reduce the irritation of the nerve. You want to improve your physical condition so that your spine is protected and its function is enhanced. After evaluating your particular case, your doctor may recommend one or more of the following common treatment options, typically occurring in two basic steps.
Step 1: Pain control
The goal of these treatments is to control your pain so that your body is given time to heal itself:
Decreased activity. One or two days of rest in bed on a firm surface or mattress may ease severe pain caused by your disk problems. You may be most comfortable lying with your back on the floor, with hips and knees bent and legs elevated. But because you need to move regularly to maintain muscle tone, avoid long periods of strict bed rest — more than a day or two may even slow recovery. When not in bed, limit activities that aggravate your symptoms, such as prolonged sitting, bending and lifting.
Pain medications. Medication may be used to relieve your discomfort until the inflammation goes away and your body heals itself.
- Acetaminophen. Acetaminophen (Tylenol, others) may help control your discomfort.
- Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as aspirin and ibuprofen (Advil, Motrin, others) can relieve pain and reduce inflammation of the disk or nerve roots. Some NSAIDs, such as naproxen sodium (Aleve), may increase your risk of heart attack and stroke. It's wise to discuss your individual risk profile with your doctor to determine whether the potential benefits of taking an NSAID outweigh the risks for you.
- Neuropathic pain medications. This is a newer class of medications that appears to work well for painful nerve conditions. The medications include gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta) and tramadol (Ultram) and may be used with either acetaminophen or NSAIDs or as an alternative to them.
- Tricyclic antidepressants. Low doses of medications such as nortriptyline (Pamelor) also may relieve pain.
- Muscle relaxants. Your doctor might prescribe muscle relaxants, such as methocarbamol (Robaxin), carisoprodol (Soma) and cyclobenzaprine (Flexeril), if you have persistent back spasms.
- Corticosteroids. If your pain isn't improved through the use of these medications, corticosteroids given orally or by way of injections may help. Corticosteroids in doses that exceed your naturally occurring levels suppress inflammation. Epidural injection — injecting corticosteroids into the area around the spinal nerves — provides a strong localized anti-inflammatory effect. Some people get significant benefit with the first injection. Additional injections may be given to maximize your pain relief. Usually no more than three injections are given.
- Narcotics. Your doctor may have you take narcotics, such as codeine or hydrocodone, for a short time if other options don't relieve your pain. Some medications may cause unwanted reactions if taken together, so check with your doctor if you're taking medications for other health problems.
Cold or heat therapy. Cold packs can be used initially to relieve pain. Wrap an ice pack or a bag of frozen vegetables in a piece of cloth. Hold it on the sore area for about 15 minutes, typically several times a day. To avoid frostbite, never place ice directly on your skin. Alternatively, use a warm bath, warm packs, a heating pad or a heat lamp for pain relief. Be careful not to burn your skin. If, for instance, you find that cold provides more relief than heat does, continue using cold packs, or try a combination of the two methods. Check with your doctor before using heat therapy within the first 48 hours of pain, because heat increases blood flow to the affected area and may increase inflammation and swelling (edema).
Electrical stimulation. Transcutaneous electrical nerve stimulation (TENS) delivers a tiny electrical current to key points on a nerve pathway. The current, delivered through electrodes taped to your skin, isn't painful or harmful. It's not known exactly how TENS works, but it's thought that it might relieve pain by stimulating the release of pain-inhibiting molecules (endorphins) or blocking pain fibers that carry pain impulses. Scientific literature doesn't provide strong evidence that TENS is effective at reducing low back pain when used as the only treatment. However, your doctor may use TENS in conjunction with other treatments.
Bracing. Your doctor may have you wear a back brace or corset for a short time to increase your comfort and help you to regain mobility. A brace can help you to maintain good posture and alignment during everyday activities. Wearing a brace also reduces spinal motion, decreases pressure within the affected disk and helps to keep the soft tissues of your back warm. Don't use a brace long term as it can weaken your abdominal and back muscles. Instead, strengthen these muscles through exercise in order to provide internal support to the spine.
Hydrotherapy. Hydrotherapy involves either sitting in an ordinary whirlpool bath or performing a variety of exercises — such as walking, stretching or joint range-of-motion exercises — while in water. Your doctor may suggest hydrotherapy to help relieve your pain and enhance muscle relaxation. Hydrotherapy may be helpful early on in your course of nonsurgical treatment by allowing you to stay mobile without aggravating your pain.
Traction. Traction stretches the lower back and improves pain by decreasing muscle spasms, and possibly by decreasing the pressure on the herniated disk. Treatment is typically provided using a traction machine either continuously for five to 15 minutes or intermittently, such as for two minutes followed by one minute of rest and repeated several times in one treatment session. It's typically performed under the guidance of a trained physical therapist. If the initial traction treatments provide improvement in pain, home traction devices can be used.
Step 2: Restore function
Once your pain improves, you can begin the process of strengthening and stabilizing your back.
Exercise and physical therapy. Physical activity plays a vital role in your recovery, allowing you to both control your pain and prevent future injury.
- Stretching exercises may help control initial pain symptoms. Once acute pain improves, your doctor or a physical therapist can design a rehabilitation program to help decrease the risk of recurrent injuries. Specific stretches called McKenzie maneuvers may decrease or eliminate leg and back pain for minutes to hours. These maneuvers are first tested during a screening examination by a spine physical therapist. If helpful, your therapist may then teach you how to do the maneuvers at home.
- Dynamic lumbar stabilization exercises. Rehabilitation may include exercises to help correct your posture, strengthen the muscles supporting your back and improve your flexibility. Many exercises focus on a program termed dynamic lumbar stabilization. This program includes exercises that involve coordinated use of both the abdominal and back muscles in a balanced-spine posture. Your doctor will have you start physical therapy, exercise or both as early as possible. Exercise and physical therapy are an important part of your treatment program and should become part of your permanent routine at home.
- Aerobic exercises. You may be able to participate in activities such as walking, biking, swimming or elliptical machine workouts to help control pain. Which exercises help your back pain will be specific to you. Start with a small amount of activity, such as five to 10 minutes and add minutes in the days that follow. Your goal is to comfortably work up to 30 to 40 minutes of vigorous physical activity five days each week.
Know when urgent medical care is needed
No single treatment option works best for everyone. Your doctor may have you try a range of nonsurgical treatments over time, changing from one to another based on results. With time, you and your doctor will discover which treatments are the most effective at relieving your pain and restoring function to your back.
Even if you decide to begin with nonsurgical treatment, contact your doctor immediately or go to an emergency room if any of these situations occur:
- Significant or progressive weakness of your muscles. For instance, if you had been able to lift up your foot or stand on your toes initially after your injury but now you can't, injury to your nerve may be worsening. This development may warrant surgery.
- Loss of bowel or bladder control. If you have lost the ability to maintain control of your urine, stool or both (incontinence), or have numbness in the saddle (perianal) area, it may mean that the nerves that control your bladder or bowel have been damaged and need to be surgically decompressed.
- Loss of sensation in the areas that would touch a saddle when sitting (saddle anesthesia).
- Loss of movement.
Additional signs and symptoms to be aware of include:
- Progressive increase in pain
- Fever lasting longer than 48 hours
- Pain that's worse at night or at rest
These signs and symptoms may indicate cauda equina syndrome — a very rare disorder of the nerves at the lower end of your spinal cord that can lead to permanent loss of function. Immediate medical attention and possible surgery are necessary to relieve the pressure on these nerves.
When nonsurgical treatments fail
If you try nonsurgical treatments but don't experience improvement after a period of time, you may need to consider surgery more seriously. Experts don't agree on a specific time frame for considering surgery, but many suggest waiting four to six weeks after the onset of pain, unless you have the signs or symptoms listed above. Where you fall within this range may depend on several factors, including how much the pain interferes with your daily activities, sleep, work and recreation.
Nonsurgical treatments for herniated disk: Pros and cons Herniated disk treatment options
