Disc surgery: do you get better results if you hurry?

Unless it's an emergency, disc surgery isn't the one right answer. It's a choice

Key points in 30 seconds

1. In a trial that divided 283 patients with severe leg pain into immediate surgery or non-surgical treatment first, results after one year were the same, and the surgery group got relief about twice as fast. They arrive at the same place, at different speeds.
2. So if there are no emergency signs, surgery is a choice. The reasonable answer depends on how much getting relief quickly matters in your life.
3. But non-surgical treatment doesn't mean holding out indefinitely. For leg pain that had lasted 4–12 months, the surgery group had less pain at 6 months. We check over a set period, and if things don't improve, we don't put off a surgical consultation.
4. In a trial of 216 people comparing acupuncture with sham acupuncture, acupuncture reduced leg pain more, and the difference lasted up to one year.
5. If you have trouble urinating or with bowel movements, numbness in the groin or buttocks, or feet that are steadily getting weaker, it's not a matter of choice. Get a surgical assessment right away.

What we often hear

• "The MRI shows my disc has ruptured. Do I need surgery?"
• "They say surgery makes you recover faster. If I don't have it, will it keep hurting like this?"
• "I've been putting up with it for months, and I don't know how long I should wait."
• "I wonder whether acupuncture really works."

Once you've seen the bulging disc on the screen, it's hard to believe it will go back in on its own. The thinking goes: what sticks out has to be put back, and putting it back means surgery.

This post examines that thinking through three questions. Does a ruptured disc stay as it is? Do you get better results if you rush into surgery? And what can you do while you wait?

A ruptured disc doesn't stay as it is

We covered this in detail in Director's column 012. Here, we'll just add the numbers.

In an analysis pooling 31 studies and 2,233 people in which patients treated without surgery had repeat MRIs, the rate at which discs shrank on their own differed by condition, like this.

Disc condition	Shrank on its own	Disappeared completely
Slightly bulging	13%	—
Protruding	41%	—
Broken through the outer layer	70%	15%
Fragment broken off	96%	43%

The more severely ruptured discs actually shrank more often. The current explanation is that the body recognizes the fragment outside the outer layer as foreign material and clears it away.

Seeing an image of a large rupture is not, by itself, a reason to conclude that surgery is the only way.

Do you get better results if you rush into surgery?

There's a trial that answers this question most directly.

Dutch researchers divided 283 patients who had had severe sciatica (leg pain caused by a disc) for 6–12 weeks into two paths. One group had surgery right away; the other had non-surgical treatment for 6 months, and had surgery then if they hadn't improved.

After one year, there was no difference between the two paths in disability, leg pain or how recovered patients felt. It was the same after two years.

The difference was speed. The group that had surgery right away saw leg pain fall quickly, and recovered about twice as fast. Of the patients assigned to the non-surgical path, 39% eventually had surgery, after an average of 18.7 weeks, and the rest recovered without surgery.

Same destination, different speed

What this trial says isn't "surgery is useless."

The biggest advantage of surgery is faster relief, and the destination after one year is the same.

So unless there are emergency signs, surgery isn't a question with a fixed answer but a matter of choice. Depending on whether you can afford a long time off work, how much pain you can bear right now, and how much of the burden of surgery you're willing to accept, a different choice may be right for different people.

You make the decision. We give you the information you need for it, as it is.

But you shouldn't wait indefinitely

The evidence on the other side needs to be seen too.

In another trial of 128 patients whose leg pain had lasted 4–12 months, the surgery group had less leg pain at 6 months.

Good non-surgical treatment is treatment with a set period. The evidence-based approach is to check whether things are heading in the right direction within the set period, and if not, not to delay a surgical consultation. If surgery has been recommended to you, the questions in the post on questions to ask about stenosis surgery apply to discs just as well.

What can you do while you wait?

The goal of non-surgical treatment is to buy time for the body to clear the disc. During that time, we make the pain bearable and protect your movement.

A recent trial is worth noting here. At six university hospitals in China, 216 patients with long-standing leg pain from an imaging-confirmed disc herniation were divided into real acupuncture and sham acupuncture (needles that didn't pierce the skin, at points that weren't acupuncture points), with 10 treatments over 4 weeks.

Time point	Reduction in leg pain (100-point scale)
After 4 weeks	Real acupuncture 30.8 points · sham 14.9 points → about 16 points' difference
After 1 year	Difference of 10.8 points maintained

Disability scores also improved more in the real acupuncture group. There were no serious side effects; the common ones were bruising and minor bleeding at the needle sites.

A difference from sham acupuncture means the effect can't be explained by expectation alone. But this trial also has clear limits (see below).

The evidence and limits of manual therapy such as Chuna are covered in the Chuna evidence post. For disc patients, we check the state of nerve symptoms first and decide how far to apply it.

The limits of this evidence

Shrinking and hurting less aren't the same. The analysis of shrinkage pooled imaging data. When and how fast discs shrink varies greatly from person to person, and the speed at which a disc shrinks isn't always the same as the speed at which symptoms improve. That's why treatment should be judged by symptoms and function, not by images.

The conditions of the surgery comparison trial. The Dutch trial included patients with severe sciatica of 6–12 weeks, and 39% of the non-surgical group eventually had surgery. It doesn't mean "everyone gets better with non-surgical treatment alone"; it means "a strategy of non-surgical treatment first, with surgery if needed" had the same one-year results as immediate surgery. Judgment may differ when symptoms have lasted a long time.

Why the acupuncture trial is hard to apply directly. It was done in one country, in chronic patients (average symptom duration about 3 years) who weren't using painkillers and had never had surgery. Whether it applies directly to people whose pain has just started, or to real-world care where other treatments are given alongside, needs further confirmation. The difference shrank by one year, and it's hard to fully rule out that patients guessed which group they were in. There are no studies yet comparing it directly with painkillers or surgery.

So these are the standards we use

First, we screen out cases that aren't a matter of choice. If you have trouble urinating or with bowel movements or can't hold them in, if sensation has dulled in the area that touches a bicycle seat (buttocks, groin, inner thighs), or if your ankles or toes are steadily getting weaker, it's not something to wait on. The nerve may be badly compressed, and a surgical assessment is needed right away.

Second, we look at images and symptoms separately. A large rupture doesn't necessarily need surgery, and even a small one needs assessment if nerve symptoms are getting worse. The standard isn't the screen, but which way your nerve symptoms are heading.

Third, we explain surgery as an option, as it is. We tell you plainly that immediate surgery brings faster recovery, and that non-surgical treatment reaches the same place more slowly.

Fourth, we set a period for non-surgical treatment. Waiting isn't neglect. We record your leg pain score, how far numbness has spread, how long you can walk without resting, and leg strength, and compare them at set points.

Fifth, we protect your movement. A general principle of back pain management is that continuing daily life as far as the pain allows is better for recovery than lying in bed. That movement is exactly why we manage the pain.

How we work

We look at emergency signs and nerve status first. At the first visit, we check for changes in bladder and bowel function, sensation in the saddle area, leg strength and sensation, and reflexes. If there are emergency signs, we don't treat; we immediately refer you to a place that can do a surgical assessment.

We look at images and symptoms together. In partnership with the radiology clinic on the 2nd floor of the same building, we confirm the type and location of the disc with MRI if needed. This is also where we distinguish it from spinal stenosis. We set the direction of treatment by nerve symptoms and function, not by how the image looks.

We make the waiting time bearable. We use acupuncture and pharmacopuncture (herbal acupuncture) to manage leg pain and tension around the lower back, and, within the limits of what the nerve check allows, Chuna (Korean manual therapy) to work on stiff movement. Together we make a plan for you to keep walking and doing daily activities within your pain limits.

We set a period and review with records. We record your leg pain score, extent of numbness, how long you can walk without resting, and leg strength before treatment, and compare them at each set point. If things aren't heading in a better direction, we don't repeat the same treatment; we guide you to the next step, including a surgical consultation.

We don't treat surgery as the enemy. From the start, we tell you about cases where surgery may be the better choice, such as emergency signs, steadily weakening legs, symptoms that last a long time without improving, or situations where you simply must recover quickly, and in those cases we connect you with the appropriate care.

Recovery speed and progress differ from person to person depending on the type and location of the disc, how long it has hurt, and nerve status.

What changes

Instead of deciding out of fear from a single MRI image, deciding by looking at numbers that show which way your leg pain and walking time are heading.

Whether you have surgery or not, that decision being one you chose, not one you were pushed into. That's what we're aiming for.

Sources used in this post

Source	What it studied	Result
Chiu et al., 2015	Pooled 31 imaging follow-up studies of non-surgical patients, 2,233 people	Spontaneous shrinkage: bulging 13%, protruding 41%, broken through 70%, broken-off fragments 96%. The more severe, the more it shrank
Peul et al., 2007 (NEJM), 2008 (BMJ)	283 people with severe sciatica of 6–12 weeks, randomized	Immediate surgery vs non-surgical treatment with surgery if needed: same results at 1 and 2 years, surgery group recovered about twice as fast, 39% of the non-surgical group had surgery after an average of 18.7 weeks
Bailey et al., 2020 (NEJM)	128 people with sciatica lasting 4–12 months, randomized	Surgery group had less leg pain at 6 months
Tu et al., 2024 (JAMA Intern Med)	216 people with chronic sciatica from disc herniation, sham acupuncture control	16-point difference in leg pain at 4 weeks, improved function, difference maintained to 1 year (10.8 points), no serious side effects

References

1. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation. 2015;29(2):184-195. doi:10.1177/0269215514540919. PMID: 25009200

2. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine. 2007;356(22):2245-2256. doi:10.1056/NEJMoa064039. PMID: 17538084

3. Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008;336(7657):1355-1358. PMID: 18502911

4. Bailey CS, Rasoulinejad P, Taylor D, et al. Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. New England Journal of Medicine. 2020;382(12):1093-1102. doi:10.1056/NEJMoa1912658

5. Tu JF, Shi GX, Yan SY, et al. Acupuncture vs sham acupuncture for chronic sciatica from herniated disk: a randomized clinical trial. JAMA Internal Medicine. 2024;184(12):1417-1424. doi:10.1001/jamainternmed.2024.5463

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If surgery has been recommended to you and you can't decide, please come see us once. We'll check for emergency signs first, then measure your current leg pain and walking time and look together at which way things are heading. The order in which we examine the lower back is laid out in our treatment guide.

For questions or appointments, message us in English through the messenger at the bottom right of the page, or call +82-53-716-1175.