Slipped disc – Non-surgical treatment options

In the past, people who had a slipped disc were typically advised to stay in bed for one to two weeks. But nowadays staying active is recommended 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. That is why it is a good idea to continue your daily activities if the pain allows for it. Exercise also helps you to keep fit and strengthen your core muscles. And it usually has a positive effect on your mood, too.

Relaxation exercises like Jacobson’s progressive muscle relaxation might also be worth a try to relieve back pain.

If the pain is very severe, though, there is sometimes simply no other way to deal with it than to briefly lie down and find a position that puts as little strain on your back as possible. Many people find the "psoas" position comfortable: You lie down on your back and elevate your lower legs up so that there is roughly a 90-degree angle between your lower legs and thighs.

Medication is usually used to relieve back pain or 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): The options here include diclofenac, ibuprofen and naproxen. They have a pain-relieving and anti-inflammatory effect. Because NSAIDs partially inhibit blood clotting, they can cause mild bleeding such as nosebleeds or bleeding gums, as well as severe bleeding, e.g. in the digestive tract. NSAIDs can also cause stomach ulcers or affect the functioning of the kidneys in some people. If you have asthma, cardiovascular disease or a stomach ulcer, you should ask your doctor for advice before taking NSAIDs. The risk of stomach ulcers or bleeding can be reduced by taking medications to protect the stomach, typically with proton-pump inhibitors such as omeprazole or pantoprazole.
• Acetaminophen (paracetamol): These painkillers might be an option for people who don’t tolerate NSAIDs, perhaps because of stomach problems or asthma. Higher doses of acetaminophen can damage the liver and kidneys, so adults shouldn’t 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 also important to stick to the minimum time intervals between taking tablets.

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 vary in their strength. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. Some are also available as skin patches. Possible side effects 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 (“cortisone”): Inflammation-reducing and pain-relieving drugs available as tablets, drips, or intramuscular injections. The active ingredients then spread throughout the body (“systemically”). But if used for a longer time, these kinds of steroids can increase the risk of stomach ulcers, osteoporosis, infections, skin problems, glaucoma and sugar metabolism disorders, for instance.
• Muscle relaxants: Sedatives that also relax the muscles. Like other psychotropic medications, they may 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.
• Anti-epileptic drugs (AEDs): These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). They are an option if a nerve is permanently irritated by a slipped disc. 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 these medications have also been approved for the treatment of chronic pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat and fatigue.

Anti-epileptic drugs and antidepressants are usually only an option if the symptoms have lasted for a long time and pain-relieving medications were not able to relieve them.

Exercise-based physical therapy may be an option for treating pain caused by a slipped disc. Exercises and back training are active therapies, meaning you are instructed how to do the exercises and then do them yourself.

Manual therapy and treatments based on physical stimuli can also be part of physical therapy. Manual therapy may include massages and special techniques for relaxing tense muscles or locked joints. Treatments based on physical stimuli use warming and cooling methods and tension to relieve pain. Manual therapy and treatments based on physical stimuli are referred to as passive therapies because you do not actively participate.

Common treatments include:

• Massages: Various massage techniques are used to relax muscles and ease tension.
• 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.

Occupational therapy helps you to learn how to cope with your limitations in everyday life. That might include practicing new movement patterns or developing strategies to relieve pain.

Generally, it has not been shown that these treatments can speed up recovery from a slipped disc or relieve the pain. But lots of people find massages or heat treatments to be pleasant and soothing, and others gain more confidence from exercises and strength training.

In Germany, statutory health insurers typically cover the costs of these therapies if prescribed by a doctor.

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 that aims to relieve the 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 reliable studies on these treatments, and there is no proof that they can relieve pain. The research suggests only that acupuncture might be able to offer pain relief. In Germany, the cost of acupuncture is normally covered by statutory health insurers if the back pain has lasted for at least 6 months. It makes sense to discuss this with your health insurance company beforehand.

Injection treatment usually involves local anesthetics and / or anti-inflammatory medications such as steroids being injected directly next to the irritated nerve root. This is sometimes also called periradicular therapy (PRT). 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. During this treatment, the spine is monitored using computed tomography (CT) or x-rays to make sure that the injection is given at exactly the right spot.

Injections close to the spine can have side effects such as bleeding, infection and nerve damage. If x-ray or CT is used, there is exposure to radiation as well.

Studies show that injection treatments can relieve sciatic pain for several weeks. It is not clear whether steroid injections are more effective than other injections.

It can be a good idea to take a look at how you deal with pain if the therapies you have tried out so far haven’t provided enough relief for the symptoms. How you perceive pain and how well you cope with it is also influenced by your mind. That’s why it can be helpful to identify and change harmful thoughts and behaviors.

Behavioral therapy might be worth a try for long-lasting pain, and it can be combined with other therapies. It may also help in understanding chronic pain and coping with it better in everyday life.

Different approaches can make sense depending on the type of symptoms and when they occur. That's why it's important to talk to a doctor about which therapies might be suitable, which can be combined, and which are not such a good option. It is also important that you are and remain active, such as also doing exercises you’ve learned at home or making regular walks part of your routine.

Multimodal treatment programs can be a particularly good idea if symptoms last for a longer time and become chronic. Treatment is provided by specialists from various areas of expertise, such as doctors, physical therapists and psychologists. The treatment combines things like exercise, training, relaxation techniques, medications, or cognitive behavioral therapy. Any other illnesses you might have will be taken into consideration. Multimodal pain management is offered as part of standard pain therapy or rehabilitation programs. It can also help to motivate you to stay active and try out new things, even if it's sometimes difficult.

Surgery may be an option to take the pressure off the affected nerve if the symptoms last for a longer time, considerably restrict daily life and conservative therapies haven't provided enough relief. But it is not possible to predict with any certainty whether surgery for a slipped disc will actually provide better long-lasting relief than conservative therapy. That’s why it can be a good idea to get a second medical opinion if your doctor recommends surgery, and to make a decision afterwards. Our decision aid can help you to weigh the pros and cons of the treatment.

Surgery is needed right away if the nerves are so severely affected that you experience paralysis in your legs, or your bladder or bowels no longer function properly. The latter is a sign of what is called Cauda equina syndrome. This is a special emergency, but is very rare.