Back Pain Without Surgery: What Are the Treatment Options?

Surgery has an important place in the treatment of spinal disease.

The goal should not be to avoid surgery regardless of the circumstances.

Current spine recommendations identify situations including:

• cauda equina syndrome

• severe motor deficit

• progressive neurological impairment

• persistent disabling symptoms despite appropriate non-surgical treatment

as reasons for specialist surgical assessment.

Research comparing surgery with non-surgical care explains why the decision needs nuance.

In a Dutch randomised trial involving people with sciatica caused by lumbar disc herniation, early surgery produced faster symptom relief. Over time, however, the difference between early surgery and an initially conservative strategy became considerably smaller.

Long-term research including SPORT also shows that surgery can provide substantial benefits for appropriately selected surgical candidates with imaging-confirmed disc herniation.

The correct message is neither “avoid surgery” nor “a herniated disc needs surgery”.

It is:

Surgery can be extremely valuable when there is a clear indication. But many patients have meaningful treatment possibilities before reaching that point.

“Conservative treatment” can sound passive.

It should not necessarily mean waiting several months while doing little more than taking painkillers and hoping that the problem disappears.

Depending on the individual situation, a non-surgical strategy can combine:

• remaining active within appropriate limits

• progressive rehabilitation

• physiotherapy

• rebuilding mobility and muscular capacity

• adapting activities that repeatedly aggravate the problem

• medication where appropriate

• conventional injections in certain situations

• recovery and sleep strategies

• addressing relevant nutritional or metabolic factors

• percutaneous hydrotomy

At Centre Algos, these approaches do not have to occur in a rigid sequence.

Movement, rehabilitation and hydrotomy can run alongside one another when clinically appropriate.

Modern back-pain management generally encourages people to remain active rather than resorting to prolonged bed rest.

Rehabilitation can help restore:

• mobility

• muscular capacity

• coordination

• tolerance to mechanical load

• confidence in movement

• ability to work

• ability to exercise or play sport

• everyday function

But rehabilitation can become difficult when pain remains intense.

If someone cannot comfortably walk, bend, sleep, work or exercise because of persistent pain, improving the painful and local tissue environment can make progressive rehabilitation easier.

This is why we do not necessarily separate active rehabilitation from treatment.

Percutaneous hydrotomy is one of the principal treatments used at Centre Algos for certain persistent musculoskeletal and spinal conditions.

It developed from mesotherapy and uses local intradermal or subcutaneous administration of physiological solution, with therapeutic substances adapted according to the indication and treatment protocol.

A fundamental characteristic of the technique is local tissue hydration.

Unlike conventional mesotherapy using very small volumes, percutaneous hydrotomy can use considerably greater dilution and hydration volumes.

The therapeutic objectives extend beyond simply blocking the sensation of pain.

Within hydrotomy practice they include:

• local extracellular hydration

• improving the tissue environment

• supplying therapeutic substances locally

• micronutritional support where appropriate

• modulation of the local inflammatory environment

The professional hydrotomy literature describes this approach in terms of local hydration and micronutrition; these objectives still need confirmation in controlled studies.

At Centre Algos, percutaneous hydrotomy can be considered in presentations including:

• chronic lower-back pain

• disc degeneration

• dehydrated or degenerative discs

• disc protrusion

• certain disc herniations

• some forms of sciatica and radicular pain

• degenerative lumbar problems

• certain presentations associated with spinal canal narrowing

Hydrotomy does not necessarily need to be reserved until every other option has failed.

When clinically appropriate, it can form part of the non-surgical strategy from an earlier stage alongside movement and rehabilitation.

Hydrotomy aims to act on the local tissue environment. No large controlled study has yet shown that it rehydrates or regenerates a disc, so we do not promise it.

This is important because it distinguishes the therapeutic concept from approaches aimed primarily at temporarily suppressing pain.

The intervertebral disc is a highly hydrated structure.

Its nucleus pulposus contains an extracellular matrix rich in proteoglycans that attracts and retains water. This contributes to the disc’s ability to absorb and distribute mechanical load.

With disc degeneration, the composition of this matrix changes. Proteoglycan content and water-retaining capacity can decrease, while the disc progressively loses hydration, elasticity and sometimes height.

Percutaneous hydrotomy approaches the affected spinal region from a different therapeutic perspective.

Through substantial local hydration and the administration of therapeutic substances according to the protocol used, the treatment aims to improve the local tissue hydration and biological environment of affected tissues.

Patients have reported improvements in pain and mobility; isolated imaging observations do not allow conclusions about an effect on the disc.

This is clinically interesting because improvement does not necessarily need to be understood solely as a reduction in pain perception. The therapeutic objective can also involve changes in the condition of the affected tissues.

At the same time, the level of evidence needs to be described accurately.

Clinical observations and individual before-and-after imaging cases are not the same as a large controlled MRI study using standardised measures such as disc height, T2 signal or validated degeneration scores.

Further controlled research can help determine:

• whether structural changes occur

• which types and stages of disc degeneration respond best

• changes in disc hydration

• any changes in disc structure over time

• how imaging changes correlate with pain and function

The appropriate conclusion is therefore:

Improvements in pain and function have been reported in clinical practice; controlled imaging studies are still needed to determine whether hydrotomy has an effect on the disc.

One of the most relevant clinical studies was completed in 2022 by Dr Myriam Semani as part of the university diploma in mesotherapy at Pitié-Salpêtrière / Paris VI.

The prospective multicentre study investigated large-dilution mesotherapy using mesoperfusion in chronic low-back pain, including patients with and without sciatica.

It included 47 patients aged between 25 and 82 years, treated across centres in Paris, Nice and Luxembourg.

Their back pain had been present for an average of approximately 29 months.

Many had already received previous treatment:

• 92% had undergone physiotherapy

• 40% had received infiltration treatment

• some had previously undergone surgery

Pain levels were high before treatment.

Mean pain scores were reported as:

• 7.8/10 at baseline

• 3.6/10 at day 30

• 2.1/10 at day 60

• 1.1/10 among participants with day-90 data

The study reported improvement in individual pain scores in 96% of included patients.

Functional disability also improved substantially. The median Quebec functional score decreased from 50 at baseline to 14 by the final assessment.

Analgesic use decreased during follow-up as well.

These findings are clinically important in a population whose pain had already persisted for more than two years on average.

The study was prospective and multicentre but did not have a randomised control group. Follow-up also became increasingly incomplete later in the study, particularly by day 90.

The three-month pain score should therefore be understood as the average among participants for whom three-month data were available, rather than the result of all 47 original participants.

Even with these limitations, the improvement observed in pain and function provides important clinical support for further research into large-dilution mesoperfusion and hydrotomy-related techniques.

Percutaneous hydrotomy does not exist in scientific isolation.

It belongs to a broader family of locoregional mesotherapy techniques for which clinical research is increasing.

A 2024 study evaluated spinal mesotherapy in 130 people with chronic lower-back pain.

Both treatment groups demonstrated significant improvements in pain and disability, including during follow-up.

A 2025 review subsequently examined nine studies involving more than 800 patients with chronic back-pain syndromes.

Across the included studies, spinal mesotherapy showed a consistent positive effect on pain and function, with no serious adverse events reported in the reviewed studies.

The review also positioned spinal mesotherapy as part of a broader strategy involving assessment, medical treatment and targeted physiotherapy.

These studies did not all investigate the exact same technique, medication, dilution or hydrotomy protocol.

They should therefore not be presented as direct trials of every form of percutaneous hydrotomy.

They are nevertheless scientifically relevant because they demonstrate that the wider therapeutic family of local spinal mesotherapy has an expanding clinical research base.

Pain, tissue condition and movement influence one another.

When pain becomes severe, patients often begin avoiding movement. Muscular capacity decreases, confidence falls and everyday movements can become increasingly difficult.

Treatment that reduces pain and improves the local tissue environment can create an opportunity to move again.

Rehabilitation then helps the patient use that opportunity.

We therefore do not view hydrotomy and movement as competing approaches.

Depending on the clinical situation, they can complement each other from an early stage.

The objective is not:

hydrotomy instead of movement.

Nor is it:

exercise for months before treatment can be considered.

The objective is to combine the approaches that make sense for the individual patient and restore function as effectively as possible.

Medication can remain useful in back-pain management.

Depending on the clinical presentation, conventional care can include analgesics, anti-inflammatory medication or treatments aimed at neuropathic symptoms.

Certain spinal injections can also provide meaningful symptom relief in appropriate situations.

At Centre Algos, we do not define our approach by opposing conventional medicine.

The aim is to determine which treatment or combination of treatments makes sense for the individual patient.

For someone whose pain persists despite previous physiotherapy, medication or conventional infiltrations, percutaneous hydrotomy can offer another therapeutic avenue.

We do not treat an MRI in isolation.

We treat the person.

The assessment can therefore examine:

• when the symptoms began

• where the pain is located

• whether it travels into the buttock or leg

• the nature of the pain

• what aggravates or relieves it

• numbness or tingling

• changes in muscular strength

• movement limitations

• previous injuries

• previous treatments and their results

• medication

• work and sporting demands

• sleep and recovery

• relevant health conditions

• existing MRI, CT or X-ray findings

When neurological symptoms are present, their distribution and progression become particularly important.

Imaging can help us understand structural aspects of the problem.

But imaging and symptoms always need to be interpreted together.

When hydrotomy appears appropriate, we discuss the treatment plan with the patient.

This includes:

• what appears to be contributing to the symptoms

• why percutaneous hydrotomy is being considered

• the objectives of treatment

• realistic treatment goals

• how treatment can be combined with movement or rehabilitation

• alternative approaches

• potential risks and precautions

• the anticipated treatment programme

The precise protocol depends on the condition and clinical presentation.

Treatment generally involves more than one session.

Progress can then be assessed through changes in:

• pain

• mobility

• functional ability

• neurological symptoms where relevant

• tolerance to activity

• sleep

• return to work

• return to sport

• everyday function

Where clinically relevant and appropriate, structural evolution on imaging can also form part of the broader picture.

The most meaningful outcome is often not simply a lower pain score.

It is:

What can the patient do again?

Most back pain is not an emergency.

Certain symptoms require prompt conventional medical assessment.

Seek urgent medical care in the presence of:

• new or rapidly progressive weakness in one or both legs

• loss of bladder or bowel control

• difficulty urinating associated with neurological symptoms

• numbness around the genitals, buttocks or saddle area

• symptoms suggestive of cauda equina syndrome

• severe pain following major trauma

• suspected spinal infection

• serious systemic illness

• warning signs raising concern about cancer

Progressive neurological deficit is particularly important.

In these situations, conservative or complementary treatment should not delay specialist assessment.

A diagnosis of disc degeneration, disc dehydration, disc protrusion or even a herniated disc does not automatically mean that surgery is inevitable.

Many people have meaningful non-surgical treatment possibilities.

The important questions are:

What is producing the symptoms?

Does the MRI correspond with the clinical picture?

Is a nerve involved?

Is there a neurological problem requiring urgent treatment?

Why has recovery stalled?

Which combination of treatments offers the best opportunity to restore pain-free movement and function?

At Centre Algos, this can combine movement and rehabilitation with percutaneous hydrotomy.

Hydrotomy adds another therapeutic dimension because its objective does not have to stop at pain reduction.

It aims to act on the local tissue environment, alongside movement and rehabilitation.

Clinical experience includes reported improvements in pain, mobility and function. Controlled studies are still needed to clarify their extent.

Surgery remains extremely important when there is a clear indication.

But when surgery is not required, the alternative is not simply to live with the pain.

There are other treatment possibilities.

Can a dehydrated spinal disc become hydrated again?

Disc hydration is dynamic. Intervertebral discs naturally gain and lose water according to loading and rest. In degeneration, their ability to retain water can become impaired. Hydrotomy does not promise to rehydrate a disc.

What can you expect from percutaneous hydrotomy for a disc?

It aims to act on the local tissue environment, alongside movement and rehabilitation. No large controlled study shows that it regenerates a disc, so we do not promise it.

Is hydrotomy only intended to relieve pain?

No. Pain reduction is an important goal; hydrotomy also aims at local tissue hydration and, where indicated, micronutritional support.

Can hydrotomy be considered for disc-related back pain?

It can be discussed after a clinical assessment, alongside movement and rehabilitation. The MRI alone does not show whether it is suitable.

Can hydrotomy help sciatica?

Hydrotomy can form part of the treatment strategy for certain disc-related or radicular presentations. Progressive weakness or symptoms suggesting cauda equina syndrome require urgent conventional medical assessment.

Can hydrotomy and physiotherapy be combined?

Yes. Treatment and rehabilitation can complement one another. Hydrotomy does not necessarily need to wait until physiotherapy has been exhausted.

What if physiotherapy or previous injections did not help?

Failure of previous treatments does not automatically mean that surgery is the only remaining possibility. The next step depends on the diagnosis, neurological findings and clinical situation. Hydrotomy can be considered as another non-surgical option where appropriate.

Does an abnormal MRI always explain my back pain?

No. Disc degeneration, bulges and protrusions can also occur in people without symptoms. MRI findings must therefore be interpreted together with symptoms and clinical examination.

Is percutaneous hydrotomy the same as mesotherapy?

They are related but not identical. Percutaneous hydrotomy developed within the mesotherapy tradition but places particular emphasis on larger-volume dilution, hydration and locoregional delivery. Broader spinal mesotherapy research is therefore relevant supporting evidence, but does not represent a direct trial of every hydrotomy protocol.

How many hydrotomy sessions are needed?

The programme depends on the condition, chronicity, clinical findings and response to treatment. It is determined following individual assessment rather than applying one identical protocol to every patient.

• Yaman O, et al. The role of conservative treatment in lumbar disc herniations: WFNS Spine Committee recommendations. World Neurosurgery: X. 2024
• World Federation of Neurosurgical Societies. Lower back pain and lumbar disc herniation recommendations
• Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR American Journal of Neuroradiology. 2015
• Brinjikji W, et al. MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls. AJNR American Journal of Neuroradiology. 2015
• Peul WC, et al. Surgery versus prolonged conservative treatment for sciatica caused by lumbar disc herniation: five-year results of a randomised controlled trial. BMJ Open. 2013
• Lurie JD, et al. Surgical versus non-operative treatment for lumbar disc herniation: eight-year results for the Spine Patient Outcomes Research Trial. Spine. 2014
• Semani M. Intérêt des grandes dilutions en mésothérapie dans la prise en charge des lombalgies chroniques. Technique de mésoperfusion. DIU de Mésothérapie, Pitié-Salpêtrière / Paris VI. 2022
• Koszela K, et al. Efficacy and safety of spinal collagen mesotherapy in patients with chronic low back pain in a three-month follow-up. Journal of Clinical Medicine. 2024
• Koszela K, et al. The role of mesotherapy in chronic back pain syndrome: what do we know? Rheumatology International. 2025
• International Association of Percutaneous Hydrotomy. Professional and clinical material on percutaneous hydrotomy, hydration, micronutrition and regeneration

• What Is Percutaneous Hydrotomy?
• Percutaneous Hydrotomy: Effectiveness, Safety and Scientific Evidence
• Why Does Pain Become Chronic?
• Chronic Pain: What Role Can Naturopathy Play?
• Tendinopathy Without Cortisone: What Are the Alternatives?