A herniated disc is a condition that occurs anywhere along the spine but more often in the lower back. Sometimes it is called a protruding, bulging or ruptured disc. It is a common cause of sciatica and lower back pain. Low back pain will affect between 60-60% of people. A herniated disc can cause leg pain and low back pain in some people. A herniated disc can be extremely painful but most people feel better after a few weeks to months of nonsurgical treatment.
Overview
A herniated disc is when the gel-like core of a disc bursts through the tough outer wall. This is similar to the jelly doughnut filling. When the disc material touches or presses on a spinal nerve, it can cause back or leg pain, numbness, or tingling. The first steps to recovery include rest, pain medication and spinal injections. Most people feel better within six weeks. They can then return to their normal activities. Surgery may be necessary if symptoms persist.
Anatomy of the Discs
The spine is composed of 24 bones, called vertebrae. The majority of the body’s weight is carried by the lumbar (lower back)section of the spine. The five lumbar vertebrae are numbered L1 through L5. The cushiony discs act as shock absorbers and prevent the vertebrae rubbing together. The annulus is the outer ring of the disc. It is made up of fibrous bands that connect between each vertebra’s bodies. The nucleus, a center of gel-filled material in each disc, is located at the middle of each disc. A pair of spinal nerves branch out from your spine at each level. Your spinal cord and spinal nerves function as a “telephone” that allows messages or impulses to travel back-and-forth between your brain, body, and spinal cord to control sensation and movement.
What is a herniated disc in the lumbar?
A herniated disc is when the gel-like core of your disc bursts through the disc wall (annulus). This causes a chemical irritation to your spinal nerves. The pressure from the herniated disc causes pain and inflammation in the spinal nerves. The herniation will shrink over time and you might experience some or all of the relief. Most cases will resolve in 6 weeks if the leg or low back pain does not go away.
A herniated disc can be described using different terms. A bulging disc (also known as protrusion) is when the disc annulus does not break down but forms an outpouching which can press against nerves. True herniated discs (also known as slipped or cracked discs) occur when the disc annulus ruptures or cracks, allowing the gel-filled middle to escape. Sometimes, the herniation can be so severe that a fragment is left. This means that the disc has been completely removed from the spine.
Most herniated discs are found in the lumbar spine. This is where the spinal nerves exit between the two lumbar vertebrae and join again to form the sciatic, which runs down your leg.
What are the signs?
The symptoms of a herniated disc can vary depending on where it is located and how you feel about pain. A herniated disc in the lumbar area can cause pain radiating from your lower back, down one or both of your legs, and sometimes to your feet. This is called sciatica. It may feel like an electric shock. This pain can be felt standing, walking, and sitting. The pain may be worsened by sitting, bending, lifting, twisting, or moving around. The most comfortable position for disc pain is to lie flat on your back, with your knees bent.
Sometimes, the pain can be accompanied by numbness or tingling in your foot or leg. There may be cramping and muscle spasms in your leg or back.
You may also experience leg muscle weakness or loss of reflexes at the knee or ankle. You may also experience foot drop, which is when your foot slides down while you walk. You should immediately seek medical attention if you feel weak in your legs or have difficulty controlling your bladder or bowel function.
What are the causes of this?
Injuries and improper lifting can cause disc bulging or herniation, or they can happen spontaneously. Aging is an important factor. Your discs become more fragile and dry as you age. The disc’s tough outer fibrous wall may become weaker. A tear in the disc’s outer wall may cause the gel-like nucleus to bulge or burst, causing nerve pain. Early disc degeneration can be caused by genetics, smoking, or other occupational or recreational activities.
Who are the affected?
People in their 30s and 40s are most likely to have herniated discs. However, middle-aged and older people are more susceptible to the condition if they engage in strenuous exercise.
Lumbar disc herniation, which is 15 times more common than cervical (neck), disc herniation, is the leading cause of lower back pain and leg pain. Disc herniation is most common in the cervical (neck), and 1 to 2% in the upper-to mid-back (thoracic).
What is the process of diagnosing a condition?
Consult your family doctor if you feel pain. To understand your symptoms and any previous injuries or conditions, your doctor will conduct a comprehensive medical history. The doctor will also determine if there are any lifestyle issues that may be causing the pain. The doctor will then perform a physical exam to identify the cause of the pain, and check for weakness or numbness.
One or more of these imaging studies may be ordered by your doctor: X-rays, MRI scans, myelograms, CT scans, or EMG. You may be referred for treatment to an orthopedist, neurosurgeon, or neurologist based on your results.
Magnetic Resonance Imaging (MRI), a noninvasive scan that uses a magnetic field in combination with radiofrequency waves, gives a detailed view to the soft tissues of your spine. Contrary to X-rays, nerves and discs can be clearly seen. The dye (contrast agent), may be injected into your bloodstream. An MRI will detect the disc that is damaged and any nerve compression. An MRI can detect bone overgrowth, spinal cord tumours or abscesses.
MRI herniated disc
Illustration and MRI image show a disc herniation at the L5 vertebra. On MRI, healthy discs look plump and white, while dry, degenerative discs appear greyish-flattened and flattened.
Myelogram, a specialised Xray in which dye is injected through a spinal tap into the spinal canal, is called a myelogram. The images are then recorded by an X-ray fluoroscopy. A myelogram is made with a dye that appears white on X-rays. This allows the doctor to see the canal and spinal cord in detail. Myelograms may show nerve damage from a herniated disc or bony overgrowth. This test may be followed by a CT scan.
The noninvasive CT scan uses an X Ray beam and a computer, to create 2-dimensional images of the spine. You may be injected with a dye (contrast drug) into your bloodstream. This test can be used to confirm which disc has been damaged.
Electromyography (EMG) & Nerve Conduction Studies (NCS). EMG tests measure your muscle’s electrical activity. The results of the EMG test are measured using small needles that are inserted into your muscles. Similar to NCS, it measures the speed at which nerves transmit an electrical signal. These tests can detect nerve damage or muscle weakness.
X-rays look at the bony vertebrae of your spine. They can show your doctor if they are too close together, arthritic changes or bone spurs. This test cannot diagnose a herniated disc.
What are the available treatments?
The first step in recovery is conservative nonsurgical treatment. This may include medication, rest and physical therapy. It can also include hydrotherapy, epidural steroid shots (ESI), chiropractic manipulation and pain management. A team approach to treating back pain can help 80% of patients to improve within 6 weeks. Your doctor may recommend surgery if you are not responding to conservative treatments.
Nonsurgical Treatments
- Self-care: Most cases of a herniated disc will resolve within two days. Your recovery will be made easier by limiting your activities, using heat therapy and taking over-the-counter medications.
- Medication: Your doctor might prescribe medication, including nonsteroidal anti-inflammatory drugs (NSAIDs), pain relievers, muscle relaxants, and steroids.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain and reduce inflammation.
- Acetaminophen (Tylenol) can be used to relieve pain, but they don’t have as many anti-inflammatory properties as NSAIDs. Analgesics and NSAIDs can cause stomach ulcers, as well as problems with the kidneys and liver.
- To control spasms, muscle relaxants such as methocarbamol or Robaxin, carisoprodol(Soma), and cyclobenzaprine/Flexeril may be prescribed.
- To reduce nerve inflammation and swelling, steroids may be prescribed. They can be taken orally (a Medrol dose packet) in a tapering dose over a 5-day period. It provides pain relief almost immediately within 24 hours.
- Steroid injections: This procedure is done under x-ray fluoroscopy. It involves the injection of corticosteroids as well as a numbing agent in the epidural area of the spine. To reduce nerve inflammation and swelling, the medicine is administered directly to the area in pain (Fig. 3). About half of epidural patients will experience relief. However, the effects are usually temporary. To achieve full effects, repeat injections may be necessary. The duration of pain relief can vary, and may last for weeks or even years. Injections can be used in conjunction with physical therapy or home exercise programs.
ESI Lumbar
- During an ESI injection the needle is inserted from behind the affected side in order to reach the epidural space and deliver steroid medication (green), to the inflamed nerve roots.
- Physical therapy: This therapy helps you get back to your full activity and prevents injury. Physical therapists will help you with proper posture, lifting and walking, as well as strengthening your stomach, legs, and lower back. You’ll be encouraged to stretch and improve the flexibility of your spine, legs and hips. Strengthening and exercise are important elements of your treatment. They should be a part of your daily fitness.
- Holistic therapies: Acupressure, nutrition/diet changes, meditation and biofeedback are all useful for managing pain and improving overall health.
Surgical Treatments
If your symptoms don’t improve after conservative treatment, surgery for a herniated disc in the lumbar area, known as a discectomy, might be an option. If you are experiencing nerve damage such as weakness or loss, surgery may be an option.
Microsurgical discectomy: A surgeon makes a small incision at the centre of your back. The spine muscles are removed to reach the damaged disc. To expose the nerve root, and disc, a portion of the bone must be removed. Special instruments are used to carefully remove the portion of the damaged disc that touches your spinal cord. A discectomy is a successful procedure that results in patients returning to work within 6 weeks.
Microendoscopic discectomy is minimally invasive. The surgeon makes a small incision at the back. To enlarge the tunnel from the vertebra, small tubes called dilators are used. To expose the nerve root or disc, a portion of the bone must be removed. To remove the disc, the surgeon can use either an endoscope (or a microscope). This method causes less muscle damage than traditional discectomy.
Clinical Trials
Clinical trials are research studies that test new therapies, such as diagnostics and procedures, on people to determine if they work and if they are safe. To improve medical care, research is ongoing. You can find information about current clinical trials including eligibility criteria, protocol and locations on the internet.
Recovery and Prevention
8 out of 10 people experience back pain at some point in their lives. Usually, it resolves within six weeks. Regular activity, a positive mental attitude and prompt return to work are important aspects of recovery. It is best for patients to be able to return to a modified or limited duty if your normal job is not possible. You can get prescriptions from your physician for this activity for a limited time.
Prevention is the key to avoiding recurrence.
- Proper lifting techniques are recommended (see Self Care for Neck and Back Pain).
- Proper posture is important when sitting, standing, moving and sleeping.
- A good exercise program is needed to strengthen the abdominal muscles and prevent injury.
- A well-designed work space
- Healthy weight and lean body mass
- Positive attitude and stress management
- No smoking
Take into account
There is a chance of the disc herniating again during your lifetime, with both surgical and nonsurgical treatments. Nonsurgical treatment can pose a risk because your symptoms might take longer to resolve. Patients who wait too long to seek nonsurgical treatment may experience less pain relief and better function than patients who choose to have surgery sooner. Research suggests that surgery after 9 to 12 months is not as effective as surgery before 9 months. Talk to your doctor about the time you should continue with nonsurgical treatments before you consider surgery. There are risks associated with surgery. Every surgical procedure has minor risks. These risks include infection, bleeding, and reactions to anaesthesia.
There are some complications that can result from surgery to repair a herniated disc.
- Nerve injury
- Infection
- Tears of the nerves’ sac (dural tear).
- Nerve compression caused by hematoma
- Recurrent disc herniation
- Additional surgery may be required
Outcomes
The overall results of microdiscectomy surgery tend to be very positive. Patients often experience more improvement in their leg pain than they do with their back pain. After a few weeks of recovery, most patients can resume their daily activities. The first sign that will improve is usually pain. Next comes overall strength and sensation. Recent research has focused on the treatment for disc herniation. Your doctor can talk to you about the benefits and drawbacks of surgical and non-surgical treatment.
I have a herniated disc in my lumbar. What’s next?
Lumbar herniated disc pain can often be acute or sudden. Although you may feel some pain in the lower back, the most telling sign of a herniated disc is leg pain that results from pressure on the sciatic nerve.
You can take some steps at home to relieve your symptoms. You can use nonsteroidal anti-inflammatory drugs such as ibuprofen to reduce stiffness and pain. You can also try applying heat or ice to the affected area. Resting for a while can also help, but you should be aware that prolonged bed rest or extended periods of time can make the pain worse.
A spine specialist may be able to help you. Most cases of herniated discs do not require surgery. However, if you’re under the care of an expert, you might find a pain management plan and treatment plan that will make you feel better faster. There are many things that we can do to reduce your pain and improve mobility, including muscle relaxants, physical therapy and steroid injections.
How do I determine if my herniated disc needs to be surgically repaired?
We may recommend surgery if you are still not feeling well after several weeks of non-surgical treatments. This can often be accomplished with minimally invasive procedures to remove the herniated material from the disc while leaving the rest of the disc intact. This will allow your disc to heal with the least amount of pressure.
We will also be watching for any signs of neurologic impairments. This refers to a condition in which a part or your body isn’t functioning as it should due to compression of your nerves and spinal cord. You can experience numbness, tingling or difficulty walking. To avoid permanent nerve damage, we recommend that you have surgery as soon as possible if anything similar occurs. We recommend that you immediately visit the emergency room if you experience loss of bladder control or bowel control.
Although herniated discs can be uncomfortable, most can heal with non-surgical treatment. A minimally invasive procedure can be performed to correct persistently disabling conditions and return you to your daily life. My goal is to help you get the results that you want.