The spine is made up of a series of interconnected bones called “vertebrae”. The disc is a combination of strong connective tissues that connects one vertebra to another and acts as a cushion between the vertebrae. The disc consists of a hard outer layer called the “annulus fibrosus” and a gel-like core called the “nucleus pulposus”. As you age, the center of the disc may begin to lose its water content and the disc becomes less effective as a cushion. This can cause the central portion of the disc to protrude through a crack in the outer layer, displacing it (called a herniated or ruptured disc). Most disc herniations occur in the lower two discs of the lumbar spine, which falls at or just below the waist.
A herniated disc can press on nerves in the spine and cause pain, numbness, tingling, or leg weakness called “sciatica.” Sciatica affects 1-2% of people, and it usually occurs between the ages of 30 and 50.
Although back pain alone without leg pain has many causes rather than disc herniation, disc herniation can also cause back pain.
WHAT IS THE TREATMENT?
Most patients (80–90%) with a herniated disc will heal without surgery. Your healthcare provider will usually begin treatment with nonsurgical methods. Your healthcare provider may recommend surgery if pain still prevents you from living your normal life after treatment is completed.
Although your leg strength may not return to normal with surgery, surgery will prevent further weakening of your leg and will also relieve your leg pain. Surgery is usually recommended for relief of leg pain (more than 90% success rate); less effective in relieving back (low back) pain.
NON-SURGICAL THERAPY
Your healthcare provider may prescribe non-surgical treatments that include short-term rest, anti-inflammatory medications to reduce swelling, pain relievers to control pain, physical therapy, exercise, or an epidural steroid injection. If you are told to rest, follow directions for how long you should stay in bed. Too much bed rest can make your joints stiff and your muscles weak, making it difficult to do activities that will help reduce pain. Ask your healthcare provider if you should continue working while you are on treatment.
Your healthcare provider can begin training and treatment with the help of a nurse or physiotherapist to help you carry out activities of your daily life without putting additional strain on your lower back.
The goals of non-surgical treatment are to improve the patient’s physical condition to protect the spine and increase overall function, while reducing nerve and disc discomfort. This can be achieved in most patients with a herniated disc with an organized care program that combines multiple treatment programs.
Some of the initial treatments your healthcare provider may prescribe include ultrasound, electrical stimulation, hot, cold, and manual “manual” treatments; these are to reduce your pain and muscle spasms and make it easier for you to start an exercise program. Traction may relieve some patients’ pain to a limited extent. Sometimes your doctor may give you a low back brace (soft, flexible back support) at the beginning of treatment to relieve your back pain, although it won’t help in curing your herniated disc. Manipulation can relieve nonspecific low back pain, but manipulation should be avoided in most cases with a herniated disc.
First of all, exercises you learn to reduce your lower back pain or leg symptoms may be gentle stretches or making changes in your body posture. When you have less pain, more challenging exercises can be used to increase flexibility, strength, endurance and return to a more normal lifestyle.
Exercise instruction should be initiated immediately and adapted to the extent of recovery as recovery progresses. Learning and maintaining a home exercise program and stretching program is an important part of treatment.
MEDICATIONS AND PAIN MANAGEMENT
Medicines used to control pain are called analgesics – painkillers. Most pain can be treated with over-the-counter medications such as aspirin, ibuprofen, naproxen, or acetaminophen. Although not very often, the doctor may sometimes prescribe a muscle relaxant. If you have persistent severe pain, the doctor may prescribe narcotic drugs for you to use for a short period of time. However, you should only take the amount of medicine you need, because taking more medicine will not make you recover faster, it may cause some unwanted side effects such as constipation and drowsiness, and may result in addiction.
All medicines should be taken only as directed. Be sure to tell the doctor about any type of medication you are taking—including over-the-counter medications—and if your doctor prescribes medication for you, let him know how it worked for you.
Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve pain and are also used to reduce swelling and inflammation caused by a herniated disc. These drugs include aspirin, ibuprofen, naproxen, and a wide variety of prescription drugs. If your doctor gives you anti-inflammatory drugs, you should carefully monitor for side effects such as stomach upset or stomach bleeding. Long-term use of prescription or nonprescription NSAIDs should be monitored by your doctor as any potential problems develop.
There are other drugs with anti-inflammatory effects. Corticosteroid drugs – by mouth or by injection – are sometimes prescribed for more severe back and leg pain because of their very potent anti-inflammatory effects. Like NSAIDs, corticosteroids can have side effects. You should discuss the risks and benefits of these medications with your doctor.
Epidural injections or “blocks” may be recommended if you have severe leg pain. These are corticosteroid injections into the epidural space (the area around the spinal nerves) and should be administered by a doctor specially trained in this technique. After the first injection, one or two more injections may be given at a later date. This should be done as part of a comprehensive rehabilitation and treatment program. The purpose of the injection is to reduce inflammation of the nerve and disc.
Trigger point injections are direct injections of local anesthetics (sometimes in combination with corticosteroids) into painful soft tissues or muscles along the spine or upper pelvis. While they sometimes work for pain control, they are not helpful in healing a herniated disc.
SURGICAL MANAGEMENT
The goal of surgery is to stop a herniated disc from putting pressure on nerves and causing discomfort, causing symptoms of pain and weakness. The most common procedure is a “discectomy,” or “partial discectomy,” in which part of the herniated disc is removed. Sometimes it may be necessary to remove a small piece of the lamina, the bone at the back of the disc, to see the disc clearly. There may be small-scale (hemi-laminotomy) or larger-scale (hemi-laminectomy) removal of the bone. Some surgeons use an endoscope or microscope in some cases.
Discectomy can be performed under local, spinal or general anaesthesia. The patient lies face down on the operating table, usually in a kneeling position. A small incision is made in the skin over the herniated disc and the muscles on the spine are pulled back from the bone. A small amount of bone may be removed so the surgeon can see the pinched nerve. The herniated disc and any loose parts are removed until their pressure on the nerve is removed. Bone spines (osteophytes) are also cleaned to ensure that the pressure on the nerve is completely removed. There is usually very little bleeding.
WHAT WILL HAPPEN AFTER SURGERY?
If your main symptom is leg pain rather than lower back pain, you can expect good results from surgery. Before surgery, your doctor will do an examination and tests to make sure the herniated disc is pressing on the nerve and causing pain. The physical examination should include a positive “straight leg raise” test that indicates sciatica and possible muscle weakness, numbness, or reflex changes. An imaging test that clearly shows nerve compression (magnetic resonance imaging [MRI], computed tomography [CT], or myelography) may also be among the additional tests. If all of these tests come back positive for you and your doctor is sure you have a nerve entrapment, you have about 90% chance of significantly getting rid of your leg pain after surgery. While you shouldn’t expect every day to be pain-free, you can keep your pain under control and continue a fairly normal lifestyle.
Most patients will not have complications after discectomy; however, you may have some bleeding, infection, tears in the protective sheath (dura mater) of the spinal nerve roots, or nerve injury. It is also possible for the disc to rupture again and cause symptoms. This is seen in approximately 5% of patients.
Contact your doctor for advice on restrictions on your post-surgical activities. It’s usually a good idea to get out of bed and walk a little right after you come out of anesthesia. Most patients go home within 24 hours sometime after surgery.
When you get home, you should avoid driving, sitting for long periods of time, lifting excessive loads and bending over for the first four weeks. Some patients will benefit from a supervised rehabilitation program after surgery. You should ask your doctor if you can do exercises to strengthen your back to prevent recurrence of your discomfort.
DO I NEED EMERGENCY SURGERY?
Very rarely, a large herniated disc can compress the nerves that control the bladder and bowel, resulting in loss of bladder or bowel control. This condition is usually accompanied by numbness and tingling in the groin or in the genital area, and is one of the very few situations in which you need emergency surgery because of a herniated disc. If this happens, call your doctor right away.
