Brief overview
- Symptoms: Depending on the location and extent of the incident, e.g., back pain radiating to a leg or arm, sensory disturbances (formication, tingling, numbness) or paralysis in the affected leg or arm, impaired bladder and bowel emptying
- Treatment: Mostly conservative measures (such as light to moderate exercise, sports, relaxation exercises, heat applications, medication), rarely surgery
- Causes and risk factors: Mostly wear and tear due to age and stress, also lack of exercise and overweight; more rarely injuries, congenital misalignments of the spine or congenital weakness of the connective tissue
- Diagnosis: physical and neurological examination, computed tomography (CT), magnetic resonance imaging (MRI), electromyography (EMG), electroneurography (ENG), laboratory tests.
What is a herniated disc?
Many people wonder what happens when a disc herniates. A herniated disc is a disease of the spine in which the soft nucleus (nucleus pulposus) protrudes from the disc located between two adjacent vertebrae.
It is usually located inside a solid fibrous ring (annulus fibrosus) that is damaged or unstable when the disc herniates. As a result, the nucleus bulges out from the disc or even passes through the ring. In rare cases, a double or multiple disc herniation can also occur if other discs prolapse at the same time or shortly after each other.
The herniated disc (disc prolapse) must be distinguished from the bulging disc (disc protrusion). Here, the inner disc tissue shifts outward without the fibrous ring of the disc rupturing. Nevertheless, complaints such as pain and sensory disturbances may occur.
Frequently, severe back pain also raises the question: lumbago or herniated disc?
Lumbago is an acute, severe pain in the lumbar region. However, it does not radiate from the lumbar spine and is not accompanied by sensory disturbances. The most common cause is muscle tension, but in rarer cases it is also caused by disc disease, inflammation or tumors.
Symptoms of a herniated disc
In many cases, a herniated disc can be recognized primarily by pain and neurological symptoms. In some patients, a herniated disc triggers signs such as burning pain, tingling or formication in the arms or legs, numbness or even paralysis in the extremities. In the case of a herniated disc, this pain may occur even when walking.
Not every herniated disc triggers the typical symptoms such as pain or paralysis. It is then often discovered only by chance during an examination. In rare cases, unusual symptoms such as nausea also appear, after a herniated disc of the thoracic spine, for example.
Symptoms of pressure on nerve roots
The signs of a herniated disc when pressure is exerted on a nerve root depend on the level of the spine at which the affected nerve root is located – in the cervical, thoracic or lumbar spine.
Occasionally, a herniated disc occurs in the cervical vertebrae (cervical disc herniation or herniated cervical spine disc). It preferably affects the intervertebral disc between the fifth and sixth or the sixth and seventh cervical vertebrae. Doctors use the abbreviations HWK 5/6 or HWK 6/7.
Symptoms of a herniated disc in the cervical region include pain radiating into the arm. Other possible signs include paresthesias and muscle paralysis in the area where the affected nerve root spreads.
Read more in the article Herniated disc of the cervical spine.
Herniated disc of the thoracic spine:
Symptoms include, for example, back pain that is usually limited to the affected section of the spine. In particular, when pressure is exerted on the respective nerve roots, the pain radiates into the supply area of the compressed nerve.
Herniated disc of the lumbar spine:
Symptoms of a herniated disc almost always originate in the lumbar spine, because body weight exerts particularly strong pressure on the vertebrae and intervertebral discs here. Doctors speak of lumbar disc herniation or “herniated lumbar disc”. Symptoms are usually caused by herniated discs between the fourth and fifth lumbar vertebrae (L4/L5) or between the fifth lumbar vertebra and the first coccygeal vertebra (L5/S1).
It is especially unpleasant when the sciatic nerve is affected by the lumbar disc herniation. This is the thickest nerve in the body. It is composed of the fourth and fifth nerve roots of the lumbar spine and the first two nerve roots of the sacrum.
The pain that occurs when the sciatic nerve is pinched is often described by patients as shooting in or electrifying. They run from the buttocks down the back of the thigh and into the foot. The discomfort often intensifies with coughing, sneezing or movement. Physicians refer to this complaint as ischialgia.
Symptoms of pressure on the spinal cord
Other signs that the disc is pressing directly on the spinal cord are dysfunctions of the bladder and bowel sphincters. They are accompanied by numbness in the anal and genital areas and are considered an emergency – the patient must go to the hospital immediately!
Symptoms of pressure on the horse’s tail
The spinal cord continues at the lower end in the lumbar region in a bundle of nerve fibers called the equine tail (cauda equina). It extends to the sacrum. This is the part of the spine that connects the two pelvic bones.
Pressure against the horse’s tail (cauda syndrome) may result in problems with urination and bowel movements. In addition, sufferers no longer have sensation in the anus and genital area, as well as on the inner thighs. Sometimes the legs are paralyzed. Patients with such symptoms should also go to the hospital immediately.
Supposed herniated disc symptoms
Pain in the leg is also not a clear sign – a herniated disc with pressure on a nerve root is only one of several possible explanations here. Sometimes a blockage of the joint between the sacrum and the pelvis (sacroiliac joint blockage) is behind it. In most cases, leg pain in back pain cannot be attributed to a nerve root.
Treatment of a herniated disc
Most patients are primarily interested in what helps with a herniated disc and how treatment and self-help proceed, if necessary.
The answer to this question depends mainly on the symptoms. For more than 90 percent of patients, conservative disc herniation treatment, i.e. therapy without surgery, is sufficient. This is especially true if the herniated disc causes pain or mild muscle weakness, but no other or more severe symptoms.
Treatment without surgery
In the category: “What should you not do with a herniated disc?” falls in most cases, to lie permanently in bed. Therefore, as part of conservative disc herniation treatment, doctors today rarely recommend immobilization or bed rest.
However, in the case of a cervical disc herniation, immobilization of the cervical spine using a cervical collar may be necessary. In the case of severe pain due to a herniated disc of the lumbar spine, stepped bed positioning is sometimes helpful in the short term.
Regular exercise is also very important in the long term in the case of a herniated disc: On the one hand, the alternation between loading and unloading the discs promotes their nourishment. On the other hand, physical activity strengthens the trunk muscles, which relieves the strain on the intervertebral discs. Therefore, exercises to strengthen the back and abdominal muscles are highly recommended in cases of herniated discs. Physiotherapists show patients these exercises as part of a back school. Afterwards, patients should exercise regularly on their own.
In addition, patients with a herniated disc may and should engage in sports, as long as they are spinal disc-friendly. This applies, for example, to aerobics, backstroke, cross-country skiing, dancing and running or jogging. Less suitable for a slipped disc are tennis, downhill skiing, soccer, handball and volleyball, golf, ice hockey, judo, karate, gymnastics, canoeing, bowling, wrestling, rowing and squash.
Many people with back pain due to a herniated disc (or other reasons) benefit from relaxation exercises. These help to relieve pain-related muscle tension, for example.
Heat applications have the same effect. That’s why they are also often part of conservative treatment for herniated discs.
If necessary, medications are used. These include, above all, painkillers such as non-steroidal anti-inflammatory drugs (ibuprofen, diclofenac, etc.). In addition to relieving pain, they also have an anti-inflammatory and decongestant effect. Other active ingredients may also be used, such as COX-2 inhibitors (cyclooxygenase-2 inhibitors) and cortisone. They also have an anti-inflammatory and pain-relieving effect. In the case of very severe pain, the doctor prescribes opiates for a short time.
In some cases, the doctor will prescribe muscle-relaxing drugs (muscle relaxants) because the muscles become tense and hardened due to the pain and a possible relieving posture. Sometimes antidepressants are useful, for example in cases of severe or chronic pain.
When does surgery have to be performed?
The doctor and patient decide together whether a herniated disc operation should be performed. The criteria for disc surgery are:
- Symptoms that indicate pressure against the spinal cord (early or immediate surgery).
- Severe paralysis or increasing paralysis (immediate surgery).
- Symptoms suggestive of pressure against the horse’s tail (cauda equina) (immediate surgery)
- Decreasing pain and increasing paralysis (rapid surgery because there is a risk that the nerve roots may already be dying)
Operation: Microsurgical discectomy
The most widely used technique in the surgical treatment of herniated discs is microsurgical discectomy (disc = disc, ectomy = removal). This involves using a surgical microscope and tiny special instruments to remove the affected disc. This is to relieve those spinal nerves that are constricted by the herniated disc and cause discomfort.
Only small skin incisions are needed to insert the surgical instruments. For this reason, the microsurgical surgical technique is one of the minimally invasive procedures.
With microsurgical discectomy, all herniated discs can be removed – regardless of the direction in which the part of the disc has slipped. In addition, the surgeon can see directly whether the distressed spinal nerve has been relieved of any pressure.
Procedure of the discectomy
To begin with, the surgeon makes a small skin incision over the diseased disc area. Then he carefully pushes the back muscles to the side and partially cuts (as little as necessary) the yellowish ligament (ligamentum flavum) that connects the vertebral bodies. This gives the surgeon the opportunity to look directly into the spinal canal with the microscope. Sometimes he has to remove a small piece of bone from the vertebral arch to improve the view.
Using special instruments, he now loosens the prolapsed disc tissue under visual control of the spinal nerve and removes it with grasping forceps. Larger defects in the fibrous ring of the disc can be sutured microsurgically. Disc fragments that have slipped into the spinal canal (sequestrum) are also removed in this way. In the final step of the disc surgery, the surgeon closes the skin with a few sutures.
Possible complications
As with any operation, there is a certain anesthetic risk with this disc surgery, as well as the risk of infections, wound healing problems and secondary bleeding.
Even with optimal disc surgery and removal of the prolapsed disc, some patients experience pulling leg pain or tingling again after weeks or months. This late consequence is called “failed back surgery syndrome”.
After the operation
As with any operation under anesthesia, the bladder sometimes needs to be emptied with a catheter on the first day after the operation. However, bladder and bowel function normalize after a very short time. In most cases, the patient is able to get up on the evening of the day of the operation.
The hospital stay usually lasts only a few days. Six or twelve months after the microsurgical discectomy, the long-term success of the disc surgery is reviewed. Imaging procedures help in this process.
Surgery: Open discectomy
Before the introduction of the surgical microscope, herniated discs were often operated on using the traditional open technique under a larger approach (larger incisions). Today, open discectomy is rarely performed, such as in cases of spinal deformity. Although their results are comparable to those of microsurgical discectomy. However, severe complications occur more frequently.
Procedure of the operation
Open discectomy essentially proceeds in the same way as microsurgical disc herniation surgery, but larger incisions are made and the surgical area is assessed from the outside rather than with a micro-optic.
Possible complications
After the operation
Sometimes on the first day after open disc surgery, the bladder must be emptied with a catheter. Within a very short time, however, bladder and bowel function return to normal.
The patient is usually allowed to get up again on the evening of the day of the operation. The next day, he usually begins physiotherapy exercises to strengthen the muscle and ligament apparatus of the back again. The patient usually stays in the hospital for only a few days.
Surgery: Endoscopic discectomy
Endoscopic disc herniation surgery is not feasible for every patient. For example, it is unsuitable if parts of the disc have detached (sequestered disc herniation) and slipped up or down in the spinal canal. Endoscopic discectomy is also not always applicable for herniated discs in the transition area between the lumbar spine and sacrum. This is because here the iliac crest blocks the way for the instruments.
Incidentally, endoscopic methods can be used not only to remove the entire intervertebral disc (discectomy), but also, if necessary, only parts of the gelatinous core (nucleus). Doctors then speak of percutaneous endoscopic nucleotomy.
Procedure of the operation
The patient lies on his or her stomach during the endoscopic disc surgery. The skin over the affected spinal segment is disinfected and locally anesthetized.
The surgeon now specifically removes disc tissue that is pressing on a nerve. After the endoscopic disc surgery, he sutures the incisions with one or two stitches or treats them with special plasters.
Possible complications
The complication rate is relatively low with endoscopic disc surgery. Nevertheless, there is a certain risk of injuring nerves. Possible consequences are sensory and movement disorders in the legs as well as functional disorders of the bladder and intestines.
In addition, as with any operation, there is a risk of infection, wound healing disorders and secondary bleeding.
Compared to microsurgical discectomy, the recurrence rate is higher with endoscopic disc surgery.
After the operation
Disc surgery with intact fibrous ring
If someone has only a mild herniated disc in which the fibrous ring is still intact, it is sometimes possible to reduce or shrink the affected disc in the area of the gelatinous core by minimally invasive surgery. This relieves the pressure on the nerve roots or spinal cord. This technique can also be used for bulging discs (in this case, the fibrous ring is always intact).
The advantage of minimally invasive surgery is that it requires only small skin incisions, is less risky than open surgery, and is usually performed on an outpatient basis. However, they are only considered in a small number of patients.
Procedure of the operation
To do this, he uses a laser, for example, which vaporizes the gelatinous core inside the disc with individual flashes of light (laser disc decompression). The gelatinous core consists of more than 90 percent water. Vaporizing tissue reduces the volume of the nucleus. In addition, the heat destroys “pain receptors” (nociceptors).
In thermolesion, the surgeon advances a thermal catheter into the interior of the disc under X-ray guidance. The catheter is heated to 90 degrees Celsius so that part of the disc tissue cooks away. At the same time, the heat is said to solidify the outer fibrous ring. Some of the pain-conducting nerves are also destroyed.
In a procedure called nucleoplasty, the doctor uses radio frequencies to generate heat and vaporize the tissue.
Chemonucleolysis involves injecting the enzyme chymopapain, which chemically liquefies the gelatinous nucleus inside the disc. After a certain waiting time, the liquefied nucleus mass is aspirated via the cannula. It is very important here that the fibrous ring of the disc in question is completely intact. Otherwise, there is a risk that aggressive enzyme will escape and cause severe damage to the surrounding tissue (such as nerve tissue).
Possible complications
One of the possible complications of minimally invasive disc surgery is bacterial discitis (spondylodiscitis). It may spread to the entire vertebral body. For this reason, the patient is usually given an antibiotic as a preventive measure.
After the operation
In the first few weeks after minimally invasive disc surgery, the patient should take it easy on himself physically. Sometimes the patient is prescribed a corset (elastic girdle) for this period to relieve the strain.
As part of surgical disc herniation treatment, the worn disc is sometimes replaced with a prosthesis to preserve the mobility of the spine. The disc implant is designed to maintain the distance between the vertebrae and their normal mobility, and to relieve pain.
So far, it is unclear which patients benefit from a disc implant and what the long-term results are. Ongoing studies have shown positive results so far. However, real long-term results are still lacking, especially since most patients are middle-aged at the time of disc surgery, so they usually still have quite a bit of life ahead of them.
Nucleus pulposus replacement
Depending on the extent of the findings and depending on the procedure, local anesthesia or a short anesthesia is often sufficient for this disc surgery. In most cases, the hydrogel is introduced by hollow needle (under X-ray vision). Affected patients are often able to get up the same day and move freely the following day. The procedure is being further developed and monitored in clinical studies worldwide. Little is known about long-term results.
Total disc replacement
In total disc replacement, the physician removes the disc and parts of the base and top plates of the adjacent vertebrae. In most models, the disc replacement consists of titanium-coated base and cover plates and a polyethylene inlay (similar to common hip replacements).
Then the surgeon inserts the disc replacement. The pressure of the spine stabilizes the implant. Within three to six months, bone material grows into the specially coated base and cover plates of the full disc prosthesis.
Already on the first day after surgery, the patient is able to stand up. During the first weeks, he must not lift heavy loads and must avoid extreme movements. An elastic girdle, which the patient puts on himself, is used for stabilization.
Total disc replacement is not suitable for patients suffering from osteoporosis (bone atrophy) or where the vertebra to be treated is unstable in terms of movement.
What are the causes of a herniated disc?
The compressed spinal cord nerves (spinal nerves) are thus strongly irritated and transmit increased pain signals to the brain. In the case of a massive contusion, the transmission of stimuli may be disturbed to such an extent that paralysis occurs.
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The frequency of herniated discs decreases again after the age of 50, because the disc nucleus loses fluid with advancing age and therefore leaks less frequently.
In addition, lack of exercise and being overweight are significant risk factors for herniated discs. Typically, the abdominal and back muscles are then additionally weak. Such instability of the body promotes incorrect loading of the intervertebral discs, since only strong trunk muscles relieve the spine.
More rarely, injuries (such as a fall down stairs or traffic accident) and congenital malpositions of the spine are the cause of a herniated disc.
In some cases, a genetically determined weakness of the connective tissue, stress and an unbalanced or incorrect diet promote the development of a herniated disc.
Herniated disc: examination and diagnosis
In case of unclear back pain, first consult your family doctor. If a herniated disc is suspected, he or she will refer you to a specialist, such as a neurologist, neurosurgeon or orthopedist.
To diagnose a herniated disc, the patient is usually questioned (anamnesis) and a thorough physical and neurological examination is performed. Only in certain cases are imaging procedures such as magnetic resonance imaging (MRI) necessary.
Doctor-patient interview
- What complaints do you have? Where exactly do they occur?
- How long have you had the complaints and what caused them?
- Does the pain increase when you cough, sneeze or move?
- Do you have trouble urinating or having a bowel movement?
This information will help the doctor narrow down the cause of the discomfort and assess which part of the spine it may be originating from.
Physical and neurological examination
The next step is physical and neurological examinations. The physician performs palpation, tapping and pressure examinations in the area of the spine and back muscles to detect abnormalities or pain points. To detect a herniated disc, he may also test the range of motion of the spine.
Imaging procedures
A computer tomography (CT) as well as a magnetic resonance imaging (MRI) make a herniated disc visible. The doctor can then see, for example, the extent of the herniation and in which direction it has occurred: In most cases, there is a mediolateral herniated disc. In this case, the leaked gelatinous core has slipped between the intervertebral holes and the spinal canal.
A lateral herniated disc can be recognized by the fact that the gelatinous nucleus has slipped sideways and is leaking into the intervertebral holes. If it thereby presses on the nerve root of the affected side, unilateral discomfort results.
More rarely, a medial disc herniation is present: Here, the gelatinous mass of the intervertebral disc nucleus emerges centrally backward toward the spinal canal (spinal cord canal) and may press directly on the spinal cord.
When are imaging procedures necessary for herniated discs?
Imaging is also necessary when back pain is accompanied by symptoms suggestive of a possible tumor (fever, night sweats, or weight loss). In these rare cases, imaging of the space between the spinal cord and the spinal sac (dural space) with an x-ray contrast agent is necessary (myelography or myelo-CT).
A normal X-ray examination is usually not useful when a herniated disc is suspected, as it only shows bone but not soft tissue structures such as intervertebral discs and nerve tissue.
Imaging procedures are not always helpful
Even if a herniated disc is discovered in an MRI or CT scan, it does not have to be the cause of the complaints that prompted the patient to visit the doctor. In fact, in many cases, a herniated disc progresses without symptoms (asymptomatic).
Measurement of muscle and nerve activity
If paralysis or sensory disturbance occurs in the arms or legs and it is unclear whether this is the direct result of a herniated disc, electromyography (EMG) or electroneurography (ENG) may bring certainty. With EMG, the treating physician measures the electrical activity of individual muscles via a needle. In cases of doubt, ENG reveals exactly which nerve roots are being squeezed by the herniated disc or whether another nerve disease is present, such as polyneuropathy.
Laboratory tests
If necessary, the physician arranges for the determination of general parameters in the blood. These include inflammation values such as the number of leukocytes and the C-reactive protein (CRP). These are important, for example, if the symptoms are possibly caused by inflammation of the intervertebral disc and adjacent vertebral bodies (spondylodiscitis).
Herniated disc: course of the disease and prognosis
In about 90 out of 100 patients, the pain and restricted mobility caused by an acute herniated disc will subside on its own within six weeks. Presumably, the displaced or leaked disc tissue is removed by the body or shifts, relieving pressure on the nerves or spinal cord.
If treatment becomes necessary, conservative measures are usually sufficient. They are therefore often the treatment of choice for a herniated disc. The duration of regeneration and chances of recovery depend on the severity of the herniated disc.
After surgery
Surgery for a herniated disc should be carefully considered. Although it is often successful, there are always patients for whom the operation does not bring the desired long-term freedom from pain.
Doctors then speak of the failed-back surgery syndrome or postdiscectomy syndrome. It occurs because the surgery has not eliminated the actual cause of the pain or has created new causes of pain. These include, for example, inflammation and scarring in the surgical area.
Another possible complication of disc surgery is damage to nerves and vessels during the procedure.
So if a patient feels worse after a disc surgery than before, there are several possible causes. In addition, follow-up surgeries are sometimes necessary. This is also the case if herniated discs occur again later in patients who have undergone surgery.
So far, there is no way to know for sure in advance which patients with herniated discs will benefit most from disc surgery.
Herniated disc: Prevention
A healthy, strong core musculature is a prerequisite for the body to cope with everyday challenges. Preventive measures include:
- Watch your body weight: excess weight puts strain on the back and promotes disc herniation.
- Exercise regularly: walking, jogging, cross-country skiing, crawling and backstroke, dancing, water gymnastics and other types of gymnastics that strengthen the back muscles are particularly beneficial for the back.
- Certain relaxation techniques such as yoga, Tai Chi and Pilates also promote good posture and help strengthen the trunk and back.
- Position objects that you use often at a height that is easy to reach: it takes the strain off your eyes and arms and prevents you from overloading your cervical spine. This is also important in a back-friendly workplace.
- Avoid deep and soft seating; a wedge-shaped seat cushion is recommended.
- Working while standing: The workstation must be high enough so that you are (permanently) able to stand upright.
- Never lift very heavy objects with your legs extended and spine bent: instead, bend your knees, keep your spine extended, and lift the load “out of your legs”.
- Distribute the load into both hands so that the spine is evenly loaded.
- Do not angle the spine toward the opposite side when carrying loads.
- Keep your arms close to your body when carrying loads: do not shift the weight of your body backwards and avoid a hollow back.
This advice is also especially for people who have already had a herniated disc.
