Non-Surgical Treatment

Most spine problems improve without surgery. Even when a disc is herniated or a nerve is pinched, the body often heals on its own over weeks to months, and the job of nonsurgical care is to control pain and keep you functioning while that happens. Surgery is generally reserved for problems that don't improve, that are severe, or that threaten nerve function.

Physical therapy and exercise

What it is. A structured program of guided movement, stretching, and strengthening — usually led by a physical therapist — designed to reduce pain, build the muscles that support your spine, and get you moving normally again.

Why it's usually first. For both back pain and neck pain, education, staying active, and supervised exercise are recommended as first-line treatment by major guidelines¹. A large Cochrane review found that exercise produces a meaningful reduction in pain and improvement in function for chronic low back pain compared with no treatment or usual care². Importantly, no single type of exercise has proven clearly superior to the others, so programs are tailored to your needs, preferences, and abilities rather than following a one-size-fits-all routine².

Common approaches. These include general strengthening and "core" stabilization, the McKenzie method (repeated directional movements and posture training), Pilates-based programs, graded aerobic activity like walking, and manual therapy delivered by the therapist. For many people with chronic pain, combining exercise with education and strategies to overcome fear of movement works better than exercise alone¹.

What to expect. Progress is gradual, measured over weeks, and the benefit depends heavily on doing the home program consistently. Passive treatments alone (heat, ultrasound, traction, TENS units) are generally not effective on their own and are not a substitute for active exercise².

Medications

Medications are typically used alongside physical therapy, not instead of it. Depending on the problem, options may include anti-inflammatory medications (NSAIDs), short courses of muscle relaxants, certain nerve-pain medications, and, for some types of chronic pain, specific antidepressant medications that also treat pain^3,4. A short course of oral steroids is sometimes used for acute nerve pain (radiculopathy), though the benefit is modest and must be weighed against side effects³. Your physician will match medication to your specific situation, other health conditions, and other medications you take.

Epidural steroid injections (ESIs)

What they are. An injection of anti-inflammatory steroid medication (often with a numbing medication) into the epidural space — the area just outside the covering of the spinal nerves. The goal is to calm inflammation around an irritated nerve root, usually to relieve the arm or leg pain of a pinched nerve.

How well they work. Epidural steroid injections are best thought of as a bridge, not a cure. They are most helpful for the radiating nerve pain (radiculopathy) caused by a herniated disc, where there is good evidence for short- to intermediate-term relief, and are less effective for spinal stenosis and for pure back pain without nerve involvement^3,5. A systematic review by the American Academy of Neurology found injections are probably effective for short-term pain and disability from radiculopathy, but found insufficient evidence for long-term pain reduction — a single injection typically helps for less than about three months⁵. This is why injections are often repeated in a planned series and are paired with physical therapy to make lasting gains.

There are several ways to deliver an epidural injection, and the choice depends on your anatomy, the location of the problem, and safety considerations:

A practical point patients often ask about: the transforaminal and interlaminar routes generally produce similar long-term results, even though the transforaminal approach tends to edge out the others for early relief of disc-related leg pain^6,7. A small early benefit after any injection often comes partly from the numbing medication and fluid itself, not just the steroid³.

Safety. Serious complications are rare. Because transforaminal injections of certain long-acting ("particulate") steroids have been linked to very rare but catastrophic events, many physicians use non-particulate steroid for the first transforaminal injection as a precaution⁵.

Medial branch blocks and radiofrequency ablation (for facet joint pain)

These two procedures work together as a "test, then treat" pair for pain coming from the facet joints — the small paired joints at the back of the spine that can become arthritic and painful.

Medial branch block (MBB). The tiny medial branch nerves carry pain signals from the facet joints. In a medial branch block, these nerves are numbed with local anesthetic. This is primarily a diagnostic (prognostic) test: if numbing the nerves gives you strong, temporary relief, it confirms the facet joints are the source of your pain and predicts that the longer-lasting procedure will help⁸. Guidelines favor medial branch blocks over injections into the joint itself as the better predictor of who will respond to ablation, and many surgeons require relief from two separate blocks before proceeding, to reduce false-positive results⁸.

Radiofrequency ablation (RFA). If the blocks confirm facet pain, RFA uses heat generated at a needle tip to interrupt those same medial branch nerves, "turning down" the pain signal for a longer period — often 6 to 12 months or more, after which the nerves can regrow and the procedure can be repeated^8,9. In a randomized trial of patients carefully selected with confirmatory blocks, cooled RFA relieved pain in a substantially higher proportion than steroid injection into the joint (70% vs. 25% responders at 3 months)⁹. RFA does not reverse the underlying arthritis — it blocks the pain pathway.

Basivertebral nerve ablation (for vertebrogenic back pain)

What it is. A newer, FDA-cleared procedure for a specific type of chronic low back pain that comes from the vertebral endplates — the surfaces where the disc meets the bone of the vertebra. This "vertebrogenic" pain is carried by the basivertebral nerve (BVN), which runs inside the vertebral body. In basivertebral nerve ablation (BVNA), a probe is guided into the vertebra and heat is used to interrupt this nerve¹⁰.

Who it's for. This is a targeted therapy for a specific subgroup: people with chronic axial low back pain lasting more than 6 months, who haven't responded to conservative care, and who have a specific MRI finding called Type 1 or Type 2 Modic changes at the vertebral endplates (L3–S1)¹⁰. It is not a treatment for leg pain, nerve compression, or general back pain without these findings.

How well it works. The evidence is relatively strong for the right patients. A landmark sham-controlled trial of the Intracept procedure showed significantly greater pain relief and functional improvement than a sham procedure, and follow-up has shown the benefit is durable out to 5 years¹¹. A systematic review graded the evidence as moderate-quality, with roughly 65% of patients achieving at least 50% pain relief and about 75% achieving meaningful functional improvement at 6–12 months¹². After treatment, disability scores drop sharply and stay low out to five years¹¹.

Other nonsurgical options

Depending on the problem, your physician may also discuss spinal cord stimulation (for certain chronic nerve pain, especially after prior surgery), cognitive behavioral therapy and multidisciplinary pain programs (especially valuable for chronic pain with a large impact on daily life), and activity modification or bracing in specific situations^1,2. As with everything in this guide, these are matched to the specific diagnosis.