Q: I've recently developed a herniated disc. What are the best treatment options for this condition?

A: The treatment of a herniated disc depends on the initial symptoms and the location. Herniated discs that appear primarily in the lower back are referred to as lumbar herniations; those that appear in the neck are called cervical herniations.

With lumbar herniations, patients typically experience increasing pain in the back and down the leg, and may have numbness and weakness. If the pain can be controlled with medications, and there's no severe weakness or paralysis, we typically begin treatment with oral medications and physical therapy. Oral medications might include an anti-inflammatory, a muscle relaxer, and a narcotic; if the pain is severe, oral steroids are sometimes used. The next step in treatment might be an epidural steroid injection, in which a cortisone-type medication is injected around the herniation in the hopes of removing the inflammation from the nerve root and relieving pain.

If the pain is debilitating and cannot be controlled with these methods, surgery may be required. In addition, if the patient is experiencing significant weakness, or the ankle or foot is becoming paralyzed, we treat those cases as urgent surgeries. The sooner the compression is relieved from the nerve, the sooner the patient can recover.

With cervical herniations, similar rules apply. If the disc herniation is compressing at the nerve root and the arm is not weak, we treat it conservatively with medications, anti-inflammatories, pain relievers, and sometimes injections. Oral steroids, physical therapy, and traction may help. For refractory cases that don't resolve, surgery becomes necessary. Sometimes herniations in the neck cause spinal cord dysfunction, and those cases are more urgently treated with immediate surgery to reduce the risk of irreversible spinal cord damage. Signs of spinal cord impingement include loss of strength in the arms or legs, balance difficulties, numbness in the arms or legs, or bowel or bladder dysfunction.

When a patient is first seen for a herniated disc, if there are signs that a disc is irritating the nerve or spinal cord, an MRI is ordered. Based on the appearance of the MRI, the physician will make a recommendation as to non-operative or operative treatment. The decision is also made based on the amount of pain the patient has, the amount of weakness, and/or the amount of neurological dysfunction. Also, we tend to observe patients for a period of up to six weeks with non-operative or conservative treatment to see if symptoms improve.

An EMG can be useful during the evaluation process to document whether nerve damage is occurring. A neurologist is often brought into the case to follow the neurological injury as well. A qualified physiatrist or physical therapist who specializes in spinal disorders can help with the recovery from a herniated disc, and oftentimes a skilled chiropractor can apply treatment that will relieve local spasm and back pain or neck pain. All of these specialties are used at various times in the treatment of this condition.

To summarize, if there is not major weakness or loss of neurological function, and the pain is controllable, we typically start treatment conservatively in the form of pain management and physical therapy. If the patients progress well, they can oftentimes avoid surgery. If the symptoms persist or progress or neurological worsening occurs, then we proceed with surgery.

It is clear from several studies and clinical practice that surgery does offer the quickest and most complete relief of nerve pain and the best chance of quick nerve recovery, although if patients are healing well on their own, then at about one year out from the injury they tend to equally do well.

A board-certified orthopedic and spinal surgeon, Dr. McCance currently serves as co-director of orthopedic spine surgery at Mount Sinai Medical Center in New York City and is an attending spine surgeon at Lenox Hill Hospital. McCance received his M.D. from Columbia College of Physicians and Surgeons; performed his orthopedic surgery training at Strong Memorial Hospital in Rochester, New York; and performed additional spinal surgery training at the prestigious Minnesota Spine Center.