A recent retrospective review published in Pain Physician evaluated the outcomes of 28 massive lumbar disc herniations (LDHs) following 2-3 serial transforaminal epidural steroid injections (TFESIs) at intervals of at least 2 weeks. Many studies have reported spontaneous regression of LDHs. However, the natural history of the condition remains incompletely understood. Surgical intervention is indicated for LDHs associated with cauda equina syndrome, severe motor deficits, and intractable pain. For LDHs that only cause pain, there is currently no established optimal treatment strategy.
On MRI, 24 of the 28 LDHs showed a reduction in the size of the herniation following the serial TFESIs. These changes were also associated with clinically and statistically significant improvements in Visual Analog Scale – Pain scores. Even for those who did not experience resorption of their LDHs, their symptoms diminished to such an extent that surgery was not required.
While this study was limited by its retrospective nature and lack of a fixed interval for follow-up MRI, this study warrants further investigation into the role TFESIs likely play in the management of massive LDHs without progressive neurologic deficits.
Our experience at RSI is similar to what was reported in this study. Our philosophy has been to treat the patient first, not the MRI!