Disc Herniation
Updated: Nov 26, 2020
Spinal discs play a crucial role in the lower back, serving as shock absorbers between the vertebrae, supporting the upper body, and allowing a wide range of movement in all directions.
Disc herniation symptoms usually start for no apparent reason. Or they may occur when a person lifts something heavy and/or twists the lower back, motions that put added stress on the discs.
As a disc in the spine degenerates, the soft inner gel in the disc can leak back into the spinal canal. This is known as disc herniation, or herniated disc. Once inside the spinal canal, the herniated disc material then puts pressure on the nerve(s), causing pain to radiate down the nerve leading to sciatica or leg pain (from a lumbar herniated disc) or arm pain (from a cervical herniated disc).
This article covers how a lumbar herniated disc develops, how it is diagnosed, and the available surgical and non-surgical treatment options.
How a Lumbar Disc Herniates
A tough outer ring called the annulus protects the gel-like interior of each disc, known as the nucleus pulposus.
Due to aging and general wear and tear, the discs lose some of the fluid that makes them pliable and spongy. As a result, the discs tend to become flatter and harder. This process—known as disc degeneration—starts fairly early in life, often showing up in imaging tests in early adulthood.
When pressure or stress is placed on the spine, the disc’s outer ring may bulge, crack, or tear. If this occurs in the lower back (the lumbar spine), the disc protrusion may push against the nearby spinal nerve root. Or the inflammatory material from the interior may irritate the nerve. The result is shooting pains into the buttock and down the leg.
Other Terms for Herniated Disc: Slipped Disc, Ruptured Disc
A herniated disc may be referred to by many names, such as a slipped disc, or a ruptured or bulging disc. The term slipped disc can cause confusion since spinal discs are firmly attached to the vertebrae and do not slip or move—rather, it is just the gel-like inner material of the disc "slips" out of the inside.
Another common term for a herniated disc is a pinched nerve. This term describes the effect the herniated disc material has on a nearby nerve as it compresses or "pinches" that nerve.
A lumbar herniated disc may also be described in reference to its main symptoms, such as sciatica, which is caused by the leaked disc material affecting the large sciatic nerve. When a nerve root in the lower back that runs into the large sciatic nerve is irritated, pain and symptoms may radiate along the path of the sciatic nerve: down the back of the leg and into the foot and toes.
Sciatica may also be referred to by its main medical term, radiculopathy.
Lumbar Herniated Disc Symptoms
Symptoms of a lumbar herniated disc vary widely—from moderate pain in the back and buttock to widespread numbness and weakness requiring immediate medical care.
In the vast majority of cases, the pain eases within six weeks. But despite its short duration, the pain can be excruciating and make it difficult to participate in everyday activities and responsibilities. For some, the pain can become chronic and/or debilitating.
It is common for a herniated disc to press against, or inflame, a nearby nerve, causing pain to radiate along the length of the nerve. A lumber herniated disc is the most common cause of sciatica, leg pain along the sciatic nerve down the back of the leg.
These are some general characteristics of lumbar herniated disc pain:
Leg pain. The leg pain is typically worse than low back pain. If the pain radiates along the path of the large sciatic nerve in the back of the leg, it is referred to as sciatica or a radiculopathy.
Nerve pain. The most noticeable symptoms are usually described as nerve pain in the leg, with the pain being described as searing, sharp, electric, radiating, or piercing.
Variable location of symptoms. Depending on variables such as where the disc herniates and the degree of herniation, symptoms may be experienced in the low back, buttock, front or back of the thigh, the calf, foot and/or toes, and typically affects just one side of the body.
Neurological symptoms. Numbness, a pins-and-needles feeling, weakness, and/or tingling may be experienced in the leg, foot, and/or toes.
Foot drop. Neurological symptoms caused by the herniation may include difficulty lifting the foot when walking or standing on the ball of the foot, a condition known as foot drop.
Lower back pain. This type of pain may be described as dull or throbbing, and may be accompanied by stiffness. If the herniated disc causes lower back muscle spasm, the pain may be alleviated somewhat by a day or two of relative rest, applying ice or heat, sitting in a supported recliner or lying flat on the back with a pillow under the knees.
Pain that worsens with movement. Pain may follow prolonged standing or sitting, or after walking even a short distance. A laugh, sneeze, or other sudden action may also intensify the pain.
Pain that worsens from hunching forward. Many find that positions such as slouching or hunching forward in a chair, or bending forward at the waist, makes the leg pain markedly worse.
Quick onset. Lumbar herniated disc pain usually develops quickly, although there may be no identifiable action or event that triggered the pain.
Lumbar herniated disc symptoms are usually more severe if the herniation is extensive. Pain can be milder and limited to the low back if the disc herniation does not affect a nerve.
In some cases, low back pain or leg pain that occurs for a few days then goes away is the first indication of a herniated disc.
Rare but Dangerous Symptoms of Lumbar Herniated Disc
A loss of bladder or bowel control, lower back pain, numbness in the anal area, and/or weakness in both legs are signs of a rare but serious condition called cauda equina syndrome.
This pressure and swelling of the nerves at the end of the spinal column can lead to paralysis and other permanent impairments if treatment is delayed. Emergency medical treatment, which may include testing and surgery, is needed if these symptoms occur.
Location of Nerve Impingement Is Key
Symptoms of a herniated disc can vary depending on the location of the nerve, as nerve pathways are different at each level of the spine.
Symptoms attributed to a herniated lumbar disc may have other causes. A thorough physical exam, medical evaluation, and sometimes diagnostic imaging tests are commonly needed to determine the source of pain and other symptoms.
Lumbar Herniated Disc: Causes and Risk Factors
Pain caused by a lumbar herniated disc can seem to occur suddenly, but it is usually the result of a gradual process.
The spinal discs in children have a high water content, which helps the discs stay flexible as they act as cushions between the vertebrae. Over time as part of the normal aging process, the discs begin to dry out. This leaves the disc’s tough outer ring more brittle and vulnerable to cracking and tearing from relatively mild movements, such as picking up a bag of groceries, twisting the lower back while swinging a golf club, or simply turning to get in the car.
A less common cause of lumbar herniated discs is a traumatic injury, such as a fall or car accident. An injury can put so much pressure on a disc in the lower back that it herniates.
Risk Factors for Lumbar Herniated Disc
Factors that may add to the risk of developing a lumbar herniated disc include:
Age. The most common risk factor is being between the ages of 35 and 50. The condition rarely causes symptoms after age 80.
Gender. Men have roughly twice the risk for lumbar herniated discs compared with women.
Physically demanding work. Jobs that require heavy lifting and other physical labor have been linked to a greater risk of developing a lumbar herniated disc. Pulling, pushing, and twisting actions can add to risk if they’re done repeatedly.
Obesity. Excess weight makes one more likely to experience a lumbar herniated disc and 12 times more likely to have the same disc herniate again, called a recurrent disc herniation, after a microdiscectomy surgery. Experts believe that carrying extra weight increases the stress on the lumbar spine, making people who are obese more prone to herniation.
Smoking. Nicotine limits blood flow to spinal discs, which speeds up disc degeneration and hampers healing. A degenerated disc is less pliable, making it more likely to tear or crack, which can lead to a herniation. The medical literature is mixed on whether people who smoke are at greater risk for a new herniation following a discectomy.
Family history. The medical literature has shown a hereditary tendency for disc degeneration, and disc degeneration is associated with an increased risk for a herniation. One extensive study found that a family history of lumbar herniated discs is the best predictor of a future herniation.
While the above factors all contribute to higher risk of developing a symptomatic lumbar disc herniation, it is possible for anyone of any age to have a herniated disc. A disc can also herniate and/or become symptomatic for no known reason.
Diagnosing a Lumbar Herniated Disc
People showing symptoms of a lumbar herniated disc can expect the doctor to conduct a detailed interview and perform a thorough physical exam.
Questions to Expect
Questions about when and how the pain started are typical, particularly if there was any type of traumatic injury. Other questions may focus on:
The type of pain. The patient may be asked to describe the pain, including its location and which activities or positions make it better or worse.
Medical conditions. Other medical conditions could be a factor. Osteoporosis, for instance, increases the risk of a fracture.
Home and work life. Having a physically demanding job or regularly performing repairs or other strenuous work at home can put pressure on a lumbar disc.
Medical history. The doctor will probably inquire about previous treatments or injuries.
Family medical history. A lumbar herniated disc is more likely if a family member has the condition.
Any experience with depression or anxiety should also be part of the discussion, since this information may be helpful in planning treatment.
Physical Exam to Diagnose Lumbar Herniated Disc
The physical examination is crucial to the diagnosis, and usually includes observation of the patient bending and stretching. These assessments are typical:
Neurological check. To determine whether there is a neurological problem, the doctor typically looks for signs of loss of sensation, such as numbness, and weakness in the leg and foot. The patient may be asked to walk normally and on tiptoes to check for a condition called foot drop, in which the muscles used to flex the ankles and toes are weakened. Muscle strength and reflexes in other areas are also likely to be checked. Reflexes may be slower than normal or nonexistent.
Range of motion tests. The patient may be asked to lean forward and back and bend from side to side.
Leg raise test. One common stretch to test for a herniated disc is the straight leg raise, or LaSegue, test. For this test, the patient lies down flat on the back and the doctor gently raises the affected leg until pain is felt. If pain occurs when the leg is raised at a 30- to 70-degree angle, it is considered a sign of lumbar disc herniation. If raising the unaffected leg hurts the affected leg, it also indicates that a nerve root is impinged or irritated.
Vital signs check. An increase in pulse rate or blood pressure can be an indication of pain, and an elevated temperature may be a sign of infection.
Gait monitoring. The doctor will observe whether the patient appears to be walking slowly due to pain, or with an abnormal gait.
Lumbar spine area exam. If there is inflammation in the lumbar spine, the skin may appear abnormal or sensitive to touch.
If the doctor sees no signs of a serious problem, the pain is not severe, and there has been no traumatic injury, imaging tests may not be necessary at this point. Some doctors prefer to have the patient wait to see whether the symptoms go away within six weeks, as happens for most people.
Imaging Tests for Lumbar Herniated Disc
Imaging tests may be included at the initial visit to rule out other possible causes of the patient's symptoms such as a fracture, tumor, infection, or caudal equina syndrome .
These are the typical imaging tests used to detect a herniate disc:
MRI (magnetic resonance imaging) usually provides the most accurate assessment of the lumbar spine area, showing where a herniation has occurred and which nerves are affected. Often, an MRI scan is ordered to aid surgical planning. It can show where the herniated disc is and how it is impinging on the nerve root.
CT (computed tomography) scan is more likely if there is a reason an MRI is not advised.
X-rays are mainly used to rule out problems such as a broken bone, bone abnormalities, infection, tumor, or problems with the alignment of the spine. X-rays are not typically used on their own to diagnose a herniated disc.
CT myelogram is a computed tomography scan using contrast dye in the spinal fluid, with X-rays to view the dye. This can show both the size and location of a herniation, but is invasive.
Electromyography (EMG) can pinpoint which nerve root is impacted.
A major challenge in diagnosing a lumbar herniated disc is the need to distinguish the condition from other causes. These other causes must be ruled out to reach the correct diagnosis and begin treatment.
Non-Surgical Treatment for a Lumbar Herniated Disc
Most cases of lumbar herniated disc symptoms resolve with medicines within six weeks, so patients are often advised to start with non-surgical treatments. However, this can vary with the nature and severity of symptoms.
Initial Pain Control for a Lumbar Herniated Disc
Controlling the intense pain is the most urgent need when symptoms first appear. Initial pain control options are likely to include:
Pain medications. The doctor may recommend non-prescription non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen or naproxen to treat pain and inflammation.
Muscle relaxants. Muscle spasms may accompany a lumbar herniated disc, and these prescription medications may offer relief from the painful spasms.
Heat therapy. Applying heat can help relieve painful muscle spasms after the first 48 hours. Heating pads, a hot compress, and adhesive heat wraps are all good options. Moist heat, such as a hot bath, may be preferred.
Bed rest for severe pain is best limited to one or two days, as extended rest will lead to stiffness and more pain. After that point, light activity and frequent movement—with rest breaks as needed—is advised. Heavy lifting and strenuous exercise should be avoided.
Additional Therapies for Lumbar Herniated Disc
These other therapies are often helpful but should only be undertaken once patient has been evaluated by a Medical Doctor (preferably a Neurosurgeon or Ortho-Spine Surgeon) ):
Physical therapy is important in teaching targeted stretching and exercises for rehabilitation. The program may also teach the patient safer ways to perform ordinary activities, such as lifting and walking.
Epidural injections of steroid medications can offer pain relief in some cases. An epidural steroid injection is intended to provide enough pain relief for the patient to make progress with rehabilitation. The effects vary, and pain relief is temporary.
Cognitive behavior therapy can be helpful in managing sciatica pain. The therapy helps people control and change self-defeating behaviors. A therapist helps the patient in face-to-face or online sessions. A therapist may also be helpful in teaching techniques such as mindful meditation and visualization to reduce pain.
Massage therapy can ease back pain by increasing blood circulation, relaxing muscles, and releasing the body’s natural pain relievers, called endorphins.
The treatment options for a lumbar herniated disc will largely depend on the length of time the patient has had symptoms and the severity of the pain. Specific symptoms (such as weakness or numbness), and the age of the patient may also be factors.
Surgery for Lumbar Herniated Disc
If the pain and other symptoms of a lumbar herniated disc persist after six weeks, surgery is often considered. A lumbar herniated disc is the most common reason for spine surgery in adults during their working years.
Immediate Surgery may be recommended if:
There is severe pain and the person is having difficulty maintaining a reasonable level of daily functions, such as standing or walking.
The person is experiencing progressive neurological symptoms, such as worsening leg weakness, and/or numbness.
There is a loss of bowel and bladder functions.
Medication, physical therapy, and/or other nonsurgical treatments have not significantly eased symptoms.
In above cases, surgery is needed urgently (to prevent permanent neurological damage) before the patient has completed six weeks of nonsurgical care.
Surgery for a Lumbar Herniated Disc
Two minimally invasive procedures, microdiscectomy and endoscopic discectomy, are most commonly recommended for lumbar herniated discs. These procedures take the pressure off the nerve root and provide a better healing environment for the disc.
Usually, only the small portion of the disc that is pushing against the nerve root needs to be removed, and the majority of the disc remains intact.
Small incisions are used in a microdiscectomy. For endoscopic microdiscectomy surgery, instruments are inserted through a thin tube or tubes to minimize disruption to the surrounding tissue. A tiny camera can be inserted through a tube to provide visualization for the surgeon.
Both types of surgery are usually performed on an outpatient basis or with one overnight stay in the hospital. Most patients can return to work and their regular routines in one to three weeks.
Success Rates for Lumbar Herniated Disc Surgery
Surgery for a lumbar herniated disc has a high rate of success. One extensive medical study reported good or excellent results for more than 90% of those having a microdiscectomy or endoscopic discectomy.
The medical literature has shown great benefits for surgery compared with nonsurgical treatment, though in some cases the difference lessens over time. One large study found that people who had surgery for a lumbar herniated disc experienced far more improvement in symptoms than those having nonsurgical treatment.
While microdiscectomy and endoscopic discectomy are considered low-risk procedures, but about 10% of patients having a microdiscectomy will experience another disc herniation at the same or other location. A recurrence is more likely within the first three months, but also can happen years later. Multiple recurrences are typically addressed with lumbar fusion surgery. This removes all the disc material and stops movement of the discs.