Herniated Disk in the Lower Back

Although a herniated disk can develop at any point along the spine, it typically happens most frequently in the lower back. A bulging, protruding, or ruptured disk is occasionally referred to as such. Among the leading factors behind lower back discomfort and leg pain or sciatica, it is one of the most prevalent.

Approximately 60 to 80% of individuals will encounter low back pain at some point in their lifetime. A herniated disk can be the underlying cause of low back pain and leg pain in some of these individuals.

Despite the potential for significant discomfort, nonsurgical treatment lasting a few weeks or months is usually sufficient for most individuals to experience considerable relief from a herniated disk.

Anatomy

The vertebral column consists of 24 vertebrae that are stacked on top of each other. By joining together, these bones form a canal that safeguards the spinal cord. The lumbar spine, which comprises five vertebrae, constitutes the lower back region.

Additional parts of the spinal column consist of:

• Spinal cord and nerves: Within the spinal canal, these electrical cables transmit messages between the brain and muscles. Nerve roots extend from the spinal cord via foramen, which are openings present in the vertebrae.
• Intervertebral disks: Flexible intervertebral disks are situated between the vertebrae. Roughly half an inch in thickness, these disks are flat and circular in shape. When walking or running, intervertebral disks function as shock absorbers. Two components comprise them:
  • Annulus fibrosus: sturdy and pliable outer ring of the disk.
  • Nucleus pulposus: gelatinous and pliable center of the disk.

Description

The exertion of pressure by the gelatinous nucleus against the outer ring, which can result from either gradual degeneration or a sudden injury, can trigger a disk herniation. Exerting pressure against the outer ring can lead to lower back pain.

Continued pressure can cause the gelatinous nucleus to either protrude entirely through the outer ring or result in bulging of the ring. This compresses the spinal cord and adjacent nerve roots.

Aside from the mechanical compression of nerves, the disk material also emits chemical irritants that can cause nerve inflammation. Irritation of a nerve root can lead to a condition known as sciatica, characterized by pain, numbness, and weakness in one or both legs.

Cause

Disk degeneration, a natural process that occurs with age, is typically the cause of a herniated disk. Disks in younger individuals, including children and young adults, contain a high amount of water.

As individuals get older, the disks lose water content and gradually become less pliable. This natural process of aging makes the disks more susceptible to herniation. A herniated disk can also be caused by a traumatic event, such as a fall.

Risk Factors

Some factors can increase the likelihood of a herniated disk:

• Gender: Herniated disks are more commonly observed in males between the ages of 20 and 50.
• Improper lifting: Lifting heavy objects using the muscles in the back instead of the legs can be a contributing factor to a herniated disk, as well as lifting while twisting. Using the legs instead of the back to lift may help protect the spine.
• Weight: The additional weight of excess body fat can place increased pressure on the disks in the lower back.
• Repetitive actions that put pressure on the spine: Numerous occupations involve physically demanding tasks, such as frequent bending, twisting, lifting, or pulling. However, employing proper lifting and movement methods can aid in safeguarding the back.
• Driving on a regular basis: Remaining in a seated position for extended periods, coupled with the vibrations from the car engine, can exert pressure on the spine and intervertebral disks.
• Sedentary lifestyle: One way to potentially prevent a herniated disk is by engaging in regular exercise, as it may help reduce the risk of various medical conditions.
• Smoking: It is thought that smoking reduces the oxygen supply to the disk and accelerates its degeneration.

Symptoms

A herniated disk typically presents with low back pain as the primary symptom. This discomfort may persist for a few days before subsiding.
Other symptoms may be:

• Pain caused by pressure on the spinal nerve is often described as a sharp, shooting pain that starts from the buttock and travels down the back of one leg (Sciatica).
• Leg and/or foot may feel weak.
• Inability to control bowel or bladder function. This may be caused by the compression of spinal nerve roots, (cauda equina syndrome) and is a rare condition that may indicate a more serious problem.

Medical History and Physical Examination

Tests that may be included in the examination are:

• Neurological examination: can help identify any muscle weakness or loss of sensation (numbness or tingling). This can be assessed by:
  • Assessment of gait on both heels and toes may be done to check for muscle strength in the lower leg, and muscle strength in other areas of the body may also be evaluated.
  • Loss of sensation can be detected by examining whether there is a response to a light touch on the leg and foot.
  • Reflexes at the knee and ankle can be tested, and their absence may sometimes indicate a compressed nerve root in the spine.
• Straight leg raise (SLR) test: A specialized test that can be performed to determine the presence of a herniated disk, particularly in younger patients.If a person experiences pain below the knee and along the leg, it can be a significant indicator of a herniated disk.

Imaging Studies

• MRI: They offer high-quality images of soft tissues within the body, including intervertebral disks. It can aid in confirming the diagnosis and identifying the specific spinal nerves that are impacted.

Treatment

In the majority of cases, a herniated lumbar disk tends to gradually get better within a few days to weeks for most patients.

Nonsurgical Treatment

The first-line treatment approach for a herniated disk typically involves non-surgical methods:

• Rest: Taking bed rest for one to two days is often recommended for relieving back and leg pain caused by a herniated disk, but patients should avoid staying off their feet for extended periods. After bed rest, the patient should make sure to take frequent breaks throughout the day, and try not to sit for extended periods of time, slow down and control all physical activities, especially when bending forward or lifting, and modify daily activities to prevent aggravating the pain.
• NSAIDs: Pain relief can be achieved by taking anti-inflammatory drugs like ibuprofen or naproxen.
• Physical Therapy: The lower back and abdominal muscles can be strengthened with targeted exercises.
• Epidural steroid injection: Injecting a cortisone-like medicine into the area around the nerve can help reduce inflammation and provide short-term pain relief. There is compelling evidence that epidural injections can effectively alleviate pain in many patients who have not experienced relief from other nonsurgical treatments for at least six weeks.

Non-surgical treatments do not cure the herniated disk but can alleviate symptoms while the body naturally heals the disk. In most cases, the herniated disk dissolves and is reabsorbed by the body over time.

Surgical Treatment

Surgery is only necessary for a small proportion of patients with lumbar disk herniation. Typically, spine surgery is advised only if the painful symptoms persist after a period of nonsurgical treatment or if the patient experiences the following symptoms:

• Weakness of the muscles
• Problems with walking
• Loss of control over the bladder or bowel

Microdiscectomy

The surgical procedure used to treat a single herniated disk is microdiscectomy, which involves the removal of the herniated part of the disk along with any additional fragments that may be compressing the spinal nerve. A more extensive surgery may be necessary if there are disk herniations affecting multiple levels.

Rehabilitation

A medical professional or a physical therapist may suggest a basic walking regimen, such as 30 minutes per day, in addition to targeted exercises to improve the strength and flexibility of the back and legs. To minimize the possibility of recurring herniation, patients may be advised to avoid bending, lifting, and twisting during the initial weeks after the surgery.

The recurrence rate of a herniated disk is about 20 to 25%, regardless of whether the patient undergoes surgical or nonsurgical treatment. A potential drawback of nonsurgical treatment is that it may take a prolonged time for the symptoms to alleviate.

Patients who delay surgery and opt for nonsurgical treatment for an extended period may experience lesser improvement in pain and functioning than those who opt for surgery sooner.

Literature has indicated that surgical outcomes may not be as favorable if surgery is performed beyond 9 to 12 months after the onset of symptoms compared to those who undergo surgery earlier. Our doctors at Complete Orthopedics will discuss with you the duration for which you should attempt nonsurgical treatments before contemplating surgery.

Surgical Risks

• Injury to the nerve
• Infection
• Dural Tear
• Nerve compression caused by a hematoma.
• Herniated disk returns
• Possibility of requiring additional surgery

A microdiscectomy surgery typically yields positive outcomes. Patients usually experience greater improvement in leg pain than in back pain after microdiscectomy surgery. After a recovery period following surgery, the majority of patients are able to resume their normal activities.

The usual pattern of improvement after surgery is for pain to be the first symptom to subside, followed by improvement in the overall strength of the leg, and finally improvement in sensation.

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