When Should a Herniated Disc Be Operated On?

A herniated disc is one of the most common spinal conditions. In France alone, approximately 30,000 patients undergo surgery each year for lumbar disc herniation, while 120,000 are treated conservatively. But the vast majority of herniated discs heal without surgery. So when does an operation become necessary?

Dr Christian Dimitriu, a neurosurgeon specialising exclusively in spinal surgery, answers the most frequent questions from his patients.

Most herniated discs heal without surgery

This is a well-established medical fact: 60 to 90% of patients suffering from sciatica caused by a herniated disc improve within 6 to 12 weeks with conservative treatment. The herniation resolves spontaneously in more than two thirds of cases.

Conservative treatment includes:

• Relative rest (no strict bed rest — staying active is important)
• Pain relief medication and anti-inflammatory drugs
• Physiotherapy and muscle strengthening
• Epidural injections for persistent pain

Dr Dimitriu systematically prioritises conservative treatment. Surgery is only proposed after failure of well-conducted medical treatment for 6 to 8 weeks, or in cases of neurological emergency.

3 situations where surgery is urgent

Fewer than 10% of symptomatic herniated discs require an operation. But certain situations constitute surgical emergencies:

1. Cauda equina syndrome

This is the absolute emergency in spine neurosurgery. The herniation compresses the cauda equina nerves, causing urinary disturbances (difficulty urinating or incontinence), loss of sensation in the perineal area and weakness in both legs. The patient must be operated on within hours to prevent permanent damage.

2. Paralysing sciatica

When the herniation severely compresses a nerve root, the patient progressively loses strength in the foot, ankle or knee. A worsening motor deficit is an urgent surgical indication, as a nerve compressed for too long may not fully recover.

3. Hyperalgesic sciatica

Unbearable pain that resists all medical treatments, including morphine and injections, constitutes a surgical indication. The patient can no longer sleep, work or even move around.

Non-urgent indications for surgery

Outside these emergencies, surgery is considered after well-conducted conservative treatment for 6 to 8 weeks without sufficient improvement:

• Persistent and disabling pain despite 2 to 3 injections
• Major impact on quality of life (prolonged sick leave, inability to walk normally)
• Correlation between clinical symptoms and imaging (MRI or CT scan)
• Stable but bothersome sensory or motor deficit

Dr Dimitriu emphasises: “The MRI does not decide the operation. It is the correlation between what the patient experiences and what the imaging shows that guides the decision. A herniation visible on MRI but asymptomatic requires no treatment.”

How is the operation performed?

The standard procedure is microdiscectomy: the surgeon removes the disc fragment compressing the nerve through a 3 to 4 centimetre incision, under a microscope. The operation takes 30 to 45 minutes under general anaesthesia.

Results are excellent: sciatic pain disappears upon waking in the majority of cases. The patient stands up the same day and goes home within 24 to 48 hours.

Minimally invasive and endoscopic techniques, with an incision of less than one centimetre, allow even faster recovery. Day surgery (returning home the same day) is possible for simple herniations.

Frequently asked questions

Why is your doctor refusing to operate?

One of the most frequent questions in consultation: “My doctor won’t operate on me — why?”. This decision, sometimes felt as a refusal, is in reality medical protection based on solid scientific evidence.

Here are the main reasons why a spine surgeon recommends waiting:

Conservative treatment has not been tried for long enough

The medical rule is clear: 6 to 8 weeks of well-conducted conservative treatment before considering surgery. If you are at 3 weeks, even with severe pain, the surgeon will wait. This is not a lack of empathy — it is because the majority of patients improve significantly within this timeframe without intervention.

The MRI shows a herniation, but the symptoms do not match

A herniation visible on MRI is not a sufficient indication in itself. Dr Dimitriu repeats it in every consultation: “We operate on a patient, not an image.” If your pain does not precisely match the nerve compression shown on the MRI, surgery will not provide benefit. Studies show that 30% of adults over 40 have asymptomatic disc herniations visible on MRI.

The surgical risk outweighs the expected benefit

All surgery carries risks. For lumbar disc herniation, the complication rate is low (2–3%), but in certain cases — significant comorbidities, anticoagulant treatment, severe obesity — the surgeon may judge that the benefit-risk ratio is not favourable. They will instead propose optimising your general health first.

An epidural injection has not yet been attempted

Before surgery, a corticosteroid injection directly at the herniation under radiological guidance (CT or fluoroscopy) can relieve 60 to 70% of patients sufficiently to avoid the operation. If you have not had one, your surgeon will probably propose this step before operating.

Lumbar vs cervical disc herniation: surgical differences

The timing of surgery varies depending on the location of the herniation:

Lumbar herniation: waiting 6 to 8 weeks is the rule. Sciatica resolves spontaneously in 60 to 90% of cases. Surgery (microdiscectomy) is proposed in cases of conservative treatment failure or neurological emergency.

Cervical herniation: the threshold for intervention may be lowered in cases of motor deficit (arm weakness, difficulty gripping objects), as cervical lesions can progress to myelopathy — spinal cord damage that does not always recover completely if treated too late.

This is why a cervical herniation with Lhermitte’s sign (electric shock in the neck on flexion) or balance disturbances is a more urgent surgical indication than an equivalent lumbar herniation.

What to do while waiting for surgery (or if you wish to avoid it)

Waiting is not passive. While waiting for conservative treatment to take effect — or if you have decided to avoid surgery — here is what Dr Dimitriu recommends:

• Maintain adapted physical activity — walking is the best treatment for sciatica. Strict bed rest prolongs pain.
• Targeted physiotherapy — core strengthening exercises protect the disc and reduce pressure on the nerve.
• Weight management — every extra kilogram increases intradiscal pressure. A loss of 5 kg can significantly reduce symptoms.
• Stop smoking — smoking reduces disc vascularisation and slows healing. It is a major risk factor for recurrence after surgery.
• Workplace ergonomics — adjust your chair, screen at eye level, avoid prolonged flexion postures.
• Regular follow-up — a review consultation at 6–8 weeks allows reassessment and a decision on whether surgery becomes necessary.

Sources: Santé publique France (PMSI 2022), HAS (2025), SFCR, EANS.