What is a herniated disc?
The spine is made up of a series of connected bones called “vertebrae.” The disc is a combination of strong connective tissues which helps connect vertebrae together and acts as a cushion between the vertebrae. The disc is made of a tough outer layer called the “annulus fibrosus” and a gel-like center called the “nucleus pulposus.” A herniated disc is the displacement of the disc’s center (the nucleus) through a crack in the outer layer.
A herniated lumbar disc can press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg called “sciatica.” A herniated lumbar disc may also cause back pain, although back pain alone (without leg pain) can have many causes other than a herniated disc.
What treatments are available?
Most (80–90%) patients with a new or recent acute disc herniation will improve without surgery. The doctor will usually try using nonsurgical treatments for the first few weeks. If the pain still keeps you from your normal lifestyle after completing treatment, your doctor might recommend surgery. Although surgery may not return leg strength to normal, it can stop your leg from getting weaker, and relieve leg pain. Surgery is usually recommended for relief of leg pain (>90% success); surgery is less effective in relieving back pain.
Nonsurgical treatment: Your doctor may prescribe nonsurgical treatments including a very short period of rest, anti-inflammatory medications to reduce the swelling, analgesic drugs to control the pain, physical therapy, or epidural steroid injections. Some form of aerobic exercise is usually advised during the healing process, helping increase blood flow to the healing area. Most people can continue to work while they are being treated.
Medication and pain management: Most pain can be treated with nonprescription medications such as aspirin, ibuprofen, naproxen or acetaminophen. If you have severe persistent pain, your doctor might prescribe narcotics or muscle relaxants for a short time. Taking these controlled substances do not actually help you recover faster, might cause unwanted side effects (such as constipation and drowsiness) and can result in dependency. All medication should be taken only as directed.
Other medications are available that also have an anti-inflammatory effect. Corticosteroid medications — either orally or by injection — are sometimes prescribed for more severe back and leg pain because of their very powerful anti-inflammatory effect. Corticosteroids, like NSAIDs, can have side effects. Risks and benefits of this medication should be discussed with your physician.
Epidural injections may be recommended if you have severe leg pain. These are injections of corticosteroid into the epidural space (the area around the spinal nerves), performed by a doctor with special training in this technique. The initial injection may be followed by one or two more injections at a later date, and should be done as part of a comprehensive rehabilitation and treatment program.
Surgery: The goal of surgery is to make the herniated disc stop pressing on and irritating the nerves, causing symptoms of pain and weakness. The most common procedure is called a “discectomy” or “partial discectomy,” in which part of the herniated disc is removed. In order to see the disc clearly, sometimes it is necessary to remove a small portion of the lamina, the bone behind the disc. A microscope is typically utilized for better visualization.
The herniated disc and any loose pieces are removed until they are no longer pressing on the nerve. Any bone spurs (osteophytes) are also taken out to make sure that the nerve is free of pressure. Usually, there is very little bleeding.
What can I expect after surgery?
Greater than 90% of patients experience relief of leg pain after surgery. Relief of central low back pain, not typically caused by a simple disc herniation alone, is less reliable from a microscopic discectomy procedure.
Most patients will not have complications after discectomy, but it is possible you may have some bleeding, infection, tears of the protective lining of the spinal nerve roots (dura mater) or injury to the nerve. It is also possible that the disc will rupture again and cause symptoms. This occurs in about 5% of patients. Ask your doctor for recommendations on postsurgical activity restrictions. Usually you can get out of bed and walk around immediately after recovering from anesthesia. Most patients go home within 24 hours after surgery, often later the same day.
Once home, you should avoid driving, prolonged sitting, excessive lifting and bending forward for the first four weeks. Some patients will benefit from a supervised rehabilitation program after surgery. You should ask your doctor if you can exercise to strengthen your back to prevent recurrence.
How do I know if I need emergency surgery?
Very rarely, a large disc herniation may press on the nerves which control the bladder and bowel, causing loss of bladder or bowel control. This is usually accompanied by numbness and tingling in the groin or genital area and is one of the few indications that you need surgery immediately for a herniated lumbar disc. Call your doctor at once if this happens.