A herniated disc or spinal disc herniation is a common painful pathological state of the spine that is one of the specific causes of back pain. Intervertebral discs are rubbery structures between the vertebrae in the spine that consist of a soft (pulpous) nucleus and a tougher (fibrous) ring. The function of the intervertebral discs is to act as a cushion in the spine.
A herniated disc occurs when the pulpous nucleus pushes into the tears of the fibrous ring which form as a consequence of degenerative changes. Spinal disc herniation typically occurs at levels L5-S1 and L4-L5, it is less common at level L3-L4, whereas herniations in the upper segments of the spine are rare. The intervertebral disc most often bulges in the posterolateral direction, where the fibrous ring is the weakest. The direction of herniation determines which nerve root is affected.
Types of spinal disc herniation:
- Disc protrusion occurs when the magnetic resonance imaging clearly shows the protrusion of the pulpous nucleus into the fibres of the fibrous ring without rupturing it.
- Disc extrusion is a hernia where the pulpous nucleus bulges through the fibrous ring, however, the inner core of the intervertebral disc remains intact.
- Sequestrated disc is a hernia characterised by a part of the intervertebral disc no longer being in contact with the pulpous nucleus. We speak of a free disc fragment or a sequestrated disc.
Some of the symptoms of disc herniation in the lumbar spine include back pain of varying intensity that can spread down the leg and decreased muscle strength. Bigger problems mostly appear when standing or sitting. Lying down usually improves the symptoms.
A cause of disc herniation are longer lasting incorrect posture and body positions, for example sitting in the office, sitting on the bicycle, sitting while driving, etc. A herniated disc is rarely a consequence of a one-time situation, it is oftentimes a longer process of a combination of poor lifestyle and poor muscle function. Risky moves that can cause disc herniation are: bending forward, sitting, and incorrect weight lifting technique.
Pain occurs during activity that involves bending forward or backward, side-bending left or right, lifting loads, sneezing, or coughing.
The intensity of pain depends on the position of the body and the location of the herniated disc; in general, it is one of the strongest pains of orthopaedic origin.
The patient feels the pain in the lumbar segment, moreover, it often spreads to the buttock, groin, thigh, shin, or even to the foot.
Pain and neurological symptoms are present in one or both feet; considerably reduced muscle strength of the lower extremities may also appear, along with a change in the sensitivity of the skin and tingling. More severe disc injuries may also result in bladder or bowel incontinence.
The majority of patients undergo a conservative treatment of disc herniation since specialised conservative rehabilitation with exercises has a good prognosis for treatment.
Absolute indications for surgical treatment are rare, for example, bladder or bowel incontinence or complete loss of sense of touch in lower extremities. Despite clear indications for surgical treatment, the decision for surgical intervention remains difficult. Surgical intervention means immediate relief of pain that is often unbearable, which is why many patients opt for surgical treatment.
Conservative treatment means that pain subsides more slowly in intensity, and it can take months for it to completely disappear. Either way, a 6-month rehabilitation treatment with specialised exercises is necessary for long-term success and it can be performed postoperatively or as an entire process of conservative treatment.
If spinal stenosis is not present, conservative treatment is mostly successful and fast.