Lumbar Disc Herniation

Low Back Pain and Leg pain :: Lumbar Disc Herniation :: Lumbar spinal stenosis :: Spondylolisthesis :: Spondylolysis (Pars Defect)

Lumbar Disc Herniation refers to a fragment of disc that has moved out of its normal location and is pressing on a nerve in the low back. Most patients with lumbar disc herniations are between the ages of 20 and 50 years of age, although this condition can be seen in patients of all ages, from teenagers to patients in their 70’s.

The cause of disc herniations is not fully understood, but several factors are believed to play a role. These include genetic influences, mechanical forces (lifting heavy object for example), and wear and tear of the disc.

Some patients recall an event that initiated the pain in the low back and/or leg (For example, when lifting a heavy object). However, most patients presenting with this problem do not recall an inciting event. They describe waking up one day and feeling the pain in the back and/or leg.

Regardless of the cause, the reason discs herniate is because a tear develops in the outer part of the disc (called the annulus) and the jellylike material on the inside of the disc (called nucleus pulposus) gets forced out of this tear and presses on a nerve. If you think of the disc as a jelly donut, when you squeeze the donut some of the jelly will protrude out. This is very similar to a disc herniation. Several terms are used to describe herniated discs, such as ruptured disc, slipped disc, disc protrusion, or extruded disc. These all refer to the same problem.

You may have been told at some point that you have “bulging discs” in your low back. This is not the same thing as a disc herniation. Bulging discs are very common in the low back (and in the neck), and are the result of very mild arthritic changes. Think of bulging discs as developing wrinkles or gray hairs. Everyone gets them at some point in their lives, some sooner than others. From a surgeon’s perspective, “bulging discs” are common and are not treated surgically. In the majority of cases, bulging discs are not the cause of low back or leg pain.

Symptoms

The most common symptoms are low back pain and pain radiating into the leg. Some patients start out with only back pain (usually on left or right side of low back), and then after a few days experience shooting pain into the leg. Most often, the pain is in one leg. Some patients describe the leg symptoms as shooting pain, some as numbness/tingling, others as burning pain. The term “sciatica” is commonly used to describe these leg symptoms.

The location of symptoms in the leg can be highly variable. For example, a patient with a right L5-S1 disc herniation may have pain in the right buttock and posterior thigh, or have pain in the calf and foot. Every patient experiences these symptoms differently.

Some patients have weakness in one or more muscle groups. For example, a patient with an L4-5 disc herniation may have difficulty bringing their ankle upwards (this is called a “foot drop”). Or a patient with an L5-S1 disc herniation may have weakness in the calf, and may not be able to get up on his or her toes because of this weakness.

Bowel and bladder problems are very rare and occur with very large disc herniations that are causing severe pressure on the spinal nerves. When bowel and bladder symptoms are present, this is an emergency and surgery should be performed as soon as possible.

Diagnosis

The best test for diagnosing lumbar disc herniation is with an MRI of the lumbar spine. The MRI is a test that shows the discs and nerves in your neck. It will show whether you have a pinched nerve and precisely which nerve(s) is pinched. Remember that most disc herniations get better on their own within a few weeks. So do not be alarmed if your physician does not order an MRI right away.

If you cannot have an MRI (for example, if you have a pacemaker), the test that is ordered is called a CT myelogram.

Non-Surgical Treatment

The good news is that the natural history of lumbar disc herniation is favorable. With time, most patients have gradual resolution of their symptoms within a few weeks. About 90% of patients improve without the need for surgery.

Conservative treatment is recommended for most patients who present with symptoms of a lumbar disc herniation. Conservative treatment consists of medications, physical therapy and perhaps injections. There are a few instances when surgery should be performed right away without conservative treatment. These instances include the following:

  1. Presence of bowel or bladder dysfunction – this is a surgical emergency if these symptoms are caused by a disc herniation. This is called “cauda equina syndrome”.
  2. Presence of progressive neurologic deficit – if the weakness in the leg is worsening, surgery should be performed. If there is mild weakness that is not worsening, surgery is an option but is not an absolute necessity.

As with many spine problems, there are 4 main treatment categories: medications, physical therapy, injections and surgery. Each will be discussed below:

  1. Medications:
    • Over-the-counter medications: The first medications to try are over-the-counter, such as NSAIDs (Advil, Aleve) or Tylenol. Advil and Aleve have anti-inflammatory properties and are pain relievers. Tylenol is a pain reliever but lacks anti-inflammatory properties. It is okay to take an NSAID and Tylenol if one does not work by itself.
    • Oral steroids: If your pain is more severe, an oral steroid taken for a short period of time may be helpful. Steroids do not have side effects if taken for a few days, but long-term use is not recommended. A common steroid that is prescribed for this problem is called a “Medrol dose pack”. It is taken over a period of 6 days.
    • Narcotic pain medications are prescribed for severe pain that is not relieved with the above. These are controlled substances that should only be taken for a short period of time.
    • Muscle relaxants are used for spasms. Their effectiveness for disc herniations is limited.
  2. Physical Therapy: the goal of therapy is to strengthen the low back and abdominal muscles and in doing so, “unload” the spine and discs by shifting the stress of your body weight from the discs to the surrounding muscles. The stronger the supporting muscles around your trunk, the better they can support your spine. The therapist will also teach you postural exercises that will minimize your pain. Many patients improve after 3-5 weeks of therapy. However, if you feel that your pain is worsening after each therapy session, it may be best to stop the therapy and see your physician.
  3. Chiropractic Treatment – Chiropractic adjustments are fine to try for small disc herniations as long as your chiropractor avoids forceful, high-velocity manipulative techniques. Gentle low-force techniques are fine and may help some patients. If chiropractic adjustments are helping your pain, it is fine to continue this treatment. But if you feel worse after adjustments, you should stop immediately.
  4. Bracing is generally not effective for treating lumbar disc herniations.
  5. Epidural Steroid Injections: the goal of injections is to calm down the inflammation around the nerves. Disc herniations mechanically compress nerves, and this compression leads to irritation/inflammation of the nerve. Epidurals do not get rid of the disc herniation. They “bathe” the nerve with the anti-inflammatory medicine (cortisone) to hopefully relieve the pain in the leg.

Surgical Treatment

If conservative treatment options fail to relieve symptoms, surgery is very successful in relieving leg pain. For lumbar disc herniations, surgery involves a microdiscectomy. For more on this surgery, Click here.