Size is not what decides
It is counter-intuitive, but a large herniation can cause few symptoms while a small one, well placed on a root, can be disabling. Size on the MRI does not determine management. What does is a combination of three factors: whether strength is being lost, how long it has lasted, and how much it limits your life.
In fact, one finding surprises most patients: large extruded herniations tend to reabsorb more and better than small protrusions. The body recognises the displaced fragment and reduces it. Time, in many cases, is on your side.
When surgery stops being optional
There are two scenarios that are not up for debate. The first is cauda equina syndrome: difficulty passing urine, incontinence, numbness in the saddle area and weakness in both legs. That is an immediate emergency, measured in hours.
The second is progressive motor deficit: if the strength of a muscle group is being lost week by week, waiting has a cost that may not be recoverable. A worsening foot drop is not a case for another three months of physiotherapy.
The grey zone, where almost everyone actually is
Outside those two scenarios sits the majority: severe radicular pain, without significant weakness, with an MRI showing the herniation at the right level. There the evidence is fairly clear and fairly reassuring: at one year, the results of operating and not operating tend to look much alike.
The difference is speed. Surgery relieves leg pain sooner, sometimes far sooner. So the sensible question is not “should I have surgery?” but “what is waiting costing me?” A professional who cannot work, a patient who cannot sleep, or someone three months into strong painkillers has legitimate reasons not to keep waiting.
What real conservative treatment must include
Conservative does not mean doing nothing. It means adequate, scheduled analgesia rather than as-needed; physiotherapy directed by a professional, with progression, not a sheet of exercises; staying active instead of taking to bed; and, in selected cases, an epidural injection to get through the acute phase.
If someone has had three months of pain but only took ibuprofen and rested, they have not had conservative treatment: they have waited. The difference matters, because failure of properly delivered treatment is exactly what supports a surgical indication.
What to expect from microdiscectomy
It is a small-incision operation under the microscope, removing the fragment compressing the root. Most patients walk the same day and return to desk work between the second and fourth week.
Be precise about expectations: it mainly removes leg pain. Background low back pain may improve, but that is not its purpose. And rehabilitation afterwards is not optional: trunk work is what reduces the risk of a new herniation.
Bring your imaging and settle the question
One consultation with your MRI or CT in hand is worth more than ten internet searches. Book by phone or through the form and you will be told what is there, what it means and what your options are.