Herniated Disc – Conservative Care or Surgery?

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In my practice, I commonly see patients with back pain and sciatica from a herniated disc.  The question always arises, when do you treat a herniated disc through conservative care (which includes chiropractic, physical therapy, acupuncture or massage) and when do you refer out to an orthopedic surgeon or a neurosurgeon. Does the size of the herniated disc matter?

In the past 15 years of being a chiropractor, I have seen all types of disc related conditions.  I have seen bulging discs, annular tears, herniated discs and extruded discs.  Most of the patients that have the condition just mentioned have benefited from conservative care.  In fact, the worst case I had seen where the disc was extruded (A disc extrusion occurs when the outer part of the spinal disc ruptures, allowing the inner, gelatinous part of the disc to squeeze out. Disc extrusions can occur with the ligaments in tact, or damaged.) was referred to a neurosurgeon but did not require surgery.

disc herniation sequence

So when does surgery become an option for a disc herniation?  When a patient presents with a herniated disc, I look for several things.  Are there any bowel or bladder dysfunction?  If so, then need a consult with a surgeon right away.  Are there muscle atrophy (decrease in muscle size) along with muscular weakness?  If so then a consult with a surgeon is recommended.  Aside from that most of the herniated disc can be managed without surgery.  You must correlate the patients symptoms and the imaging results and base the decision on those two factor. There are numerous studies to show that discs that are ruptured/herniated, even large ones, respond well to conservative management.  I always tell my patients if a surgeon suggests surgery, get a second and third opinion.  If you are suffering from sciatica due to a herniated disc and have questions, feel free to contact me at (847) 537-0300 or email me at drmikechoe@gmail.com

Below are some links to show the research performed on patients with herniated discs and

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025225/

“Patients with sciatica should be encouraged to be patient and submit to conservative treatment methods initially. In the presence of clinical progress, even very large disc herniations can be left to resolve naturally. Early access to surgeons and diagnostic imaging may result in unnecessary operative treatment.”

http://www.painmed.com/1/post/2011/11/is-it-safe-to-treat-massive-disc-herniations-nonoperatively.html

“Our results show that the majority of large disc extrusions might decrease in size,” Sinel et al. conclude. “Therefore disc size alone should not be one of the primary factors determining which patients should undergo surgery.” So even with a clear-cut, large disc herniation and nerve root compromise, clinical decisions should be based on the patient and not on the appearance of the disc herniation on imaging scans. “

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