Herniated disc: Non-surgical treatment

Most people with a slipped disc in the lumbar region of their spine (lower back) are offered “conservative” treatment, meaning that the treatment does not involve surgery. This mainly involves exercise, relaxation and positioning, painkillers or local anesthetics, and manual and physical therapy.

 

Some slipped discs don't cause any symptoms, whereas others lead to severe back pain. A slipped disc in the lumbar region of the spine (the lower back) can press on the sciatic nerve and cause pain that often radiates down one leg and into the foot. Most people recover from a slipped disc within six weeks without treatment. Until then there are a number of treatment options that aim to help relieve the pain and improve mobility.

In the past, people who had a slipped disc were typically advised to stay in bed for one to two weeks. Nowadays the opposite approach is taken: people are advised to stay active instead. This is because remaining in a lying position for a long time can make muscles and bones weaker, which can end up causing other problems.

 

Studies have shown that physical activity can improve mobility. However, whether people keep up with exercise or rest instead wasn't found to influence the back pain itself. So it is a good idea to try to carry out your normal daily activities as much as the pain allows. Exercise has also been proven to effectively prevent back pain from returning.

 

. How you perceive pain and how well you cope with it can be influenced by your mind.

 

If the pain is very severe, though, there is sometimes simply no other way to deal with it than to lie down and find a position that puts as little strain on your back as possible. Many people find the "psoas" position comfortable: While lying on your back, you put your lower legs on a raised platform high enough so that your knees are bent at a 90-degree angle. But it is important not to stay inactive for too long.

 

Illustration: Psoas position

 

  

There are a number of different medications for the relief of sciatic nerve pain (sciatica) caused by a slipped disc. Most of these are painkillers, but you can also use muscle relaxants and anti-inflammatory drugs. The following medications are the most commonly used. They are all available without a prescription when taken at a low dose:

 

Non-steroidal anti-inflammatory drugs (NSAIDs): These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen and naproxen. They have a pain-relieving and anti-inflammatory effect.Because NSAIDs prevent blood from clotting to an extent, they can cause bleeding. The bleeding may be mild, such as a nosebleed or bleeding gums, but more serious bleeding can sometimes also occur, for example in the stomach or bowels. In some cases NSAIDs cause stomach ulcers, too. NSAIDs may also impair the function of the kidneys. If you have asthma, a cardiovascular disease, or a stomach ulcer, you should ask your doctor for advice before taking NSAIDs. NSAIDs can also be injected into muscle tissue, although that is generally not done anymore nowadays. NSAID injections probably don't have any advantages over tablets or suppositories, but they may cause nerve damage, bleeding or inflammation at the site of injection.

Acetaminophen (paracetamol): Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. For this reason, adults should follow the information on the package insert and make sure they do not take more than 4 grams (4,000 milligrams) of acetaminophen per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.

Some of the medication options have to be prescribed by a doctor. These include:

 

Opioids: Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems and blood pressure fluctuation. Taking these drugs for a longer time can lead to habitual use and physical dependence.

Steroids: Inflammation-reducing drugs that can be used to treat various diseases systemically. It is called a systemic treatment if the medication spreads throughout the entire body. This happens when it is taken as a tablet, injected into a muscle or given through a drip (infusion).Systemic steroids can soothe inflammation and relieve pain. They can also increase the risk of certain medical problems, including stomach ulcers, osteoporosis, infections, skin problems, glaucoma and glucose metabolism disorders.

Muscle relaxants: Sedatives that also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect the functioning of your liver and cause gastrointestinal (stomach and bowel) complications. Benzodiazepines such as tetrazepam may lead to dependency if they are taken for longer than two weeks.

Anticonvulsants: These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.

Antidepressants: These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat and fatigue.

Anticonvulsants and antidepressants are typically not used unless the symptoms last for a longer period of time or the painkillers don't provide enough relief.

 

  

The treatment options for sciatica following a slipped disc also include manual therapy and treatments based on physical stimuli. Manual treatment may include massages and special techniques for relaxing tense muscles or locked joints. Treatments based on physical stimuli use warming and cooling methods to relieve pain. These treatments are also called passive therapies because patients don't have to actively participate. Common treatments include:

 

Heating and cooling: This includes the use of hot packs and heating patches, a hot bath, going to the sauna or using an infrared lamp. Heat can also help relax tense muscles. Cold packs, like cold wraps or gel packs, are also used to help soothe irritated nerves.

Ultrasound therapy: Here the lower back is treated with sound waves. The small vibrations that are produced generate heat and relax the body tissue.

There is no overall proof that passive treatments speed up recovery from a slipped disc or relieve the pain especially well. But many people find that heat or massages are pleasant and relaxing.

 

  

Treatment approaches based on traditional Asian medicine include:

 

Acupuncture: In ´´acupuncture the therapist inserts fine needles into certain points on the body. This is thought to relieve the pain..

Reiki: Reiki is a Japanese treatment which aims to relieve pain by using specific hand placements.

Moxibustion: This method is used to heat specific points on the body by placing heated needles or glowing sticks made of mugwort ("Moxa") close to those points.

There are very few good-quality studies on these treatments, and there is no proof that they help to relieve pain. Acupuncture is the only approach for which there is weak evidence that it might relieve pain – although this relief has been shown to be unrelated to where the needles are placed on the body.

 

  

Injection therapy mainly uses local anesthetics and/or inflammation-reducing medications like steroids. These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:

 

In lumbar spinal nerve analgesia, the medication is injected directly at the point where the nerve root leaves the spinal canal. This has a numbing effect on the nerve root.

In lumbar epidural analgesia, the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment the spine is monitored using computer tomography or x-rays to make sure that the injection is placed at exactly the right spot.

Injections close to the spine can have side effects such as bleeding, infection and nerve damage. A treatment involving injections over a longer period of time may also lead to muscle weakness and is associated with radiation exposure due to the use of x-rays. For this reason, only a limited number of injections may be given. It is important to carefully weigh the pros and cons of having multiple injections.

 

Studies on treatments with injections have shown that they are able to relieve sciatica for several weeks. People were able to move more easily while going about their day-to-day activities as a result. Steroid injections seem to be somewhat more effective than other types of injections.

 

  

Acute low back pain usually has no clear cause and goes away on its own after a few days. And even if a slipped disc is causing it, your body will probably be able to make the problem go away on its own within six weeks. Most treatments hardly affect the speed of recovery. Hot packs or massages might help you feel better. If you have severe pain, short-term relief can be provided by getting into a position that reduces the strain on your back and by using anti-inflammatory drugs or local anesthetics. But most of the work is usually done by the body itself.

 

If slipped disc symptoms persist for a longer time, surgery may be an option to try to relieve the pressure on the affected nerve. However, most experts believe that slipped disc surgery is done more often in Germany than is actually necessary. So it might make sense to get a second opinion if your doctor advises you to have surgery and you aren't sure whether this is the right treatment.

 

It is particularly important to stay as physically active as possible despite the pain. Exercise will not only keep your body in shape, it generally also has a positive effect on your mood. Getting enough exercise and keeping up the strength of your torso (core muscles) is key in order to stop back pain from becoming chronic. Physical activity has been scientifically proven to have a preventive effect – and it is probably the most important thing you can do to help yourself.