A person suffering from lower back, arm, neck, or leg pain may be diagnosed with a herniated disc.  In order to truly understand what this means, it is important to know what a disc is made up of and what the functions are of a healthy disc.   A disc is made up of a tough outer core and a gel-like inner material.   A disc functions as a spacer, shock absorber, and motion unit.

Functions of a Healthy Disc

When it performs its duty as a spacer, this helps the intervertebral foramen maintain a height that allows room for the nerve roots to rest without compression.  They act as a shock absorber when a person decides to jump or run, allowing the spine to compress or rebound.  They act as a motion unit, so they allow a person to flex, bend, or rotate.

Brief Description of a Herniated Disc

A herniated disc occurs when the gel-like inner material breaks through the tough outer core and compresses on the nerves that are located outside of the disc.

Causes of a Herniated Disc

There are two main causes of a herniated disc.  Wear and tear due to age is common in older patients.   A traumatic injury is another cause that could also be found in younger patients.

Symptoms of a Herniated Disc

A person suffering from a herniated disc will feel symptoms in different areas of the spine.  The spine is divided into three sections.  These are:

• Cervical
• Thoracic
• Lumbar

When the nerves outside of the discs are pressed on, symptoms will occur, such as: pain, numbness, and weakness.  A common symptom is sciatica, which is most commonly found in the lower back.

Diagnosis of a Herniated Disc

Tests to be run for a herniated disc are a MRI or CT scan.  They can confirm a herniated disc or rule out any other problems.

Treatment of a Herniated Disc

Most people who are diagnosed with a herniated disc will not need surgery.   The first course of treatment will be a set of nonsurgical treatments that will be done for a period of four to six weeks.  Most herniated discs will begin to heal within this time period.

If they do not heal, surgical options may be discussed.  The traditional back surgery is not as common these days.  There are a couple of surgical options that will allow a person to have outpatient surgery without the risks of a traditional open back surgery.

Disc replacement surgery is also an option that requires a longer recovery period and has risks similar to the open back surgery.

Good Candidates for Herniated Disc Surgery

A doctor will take into consideration a number of factors that will help him/her determine if a patient will benefit from herniated disc surgery.

A herniated disc can be a painful and disabling health issue.  The good news is that most people can heal over a period of one to six months without needing surgery.  Even better news is that because of advanced technology, there are less invasive surgical treatments that allow a patient to feel relief on the same day of the procedure, as well as return to normal daily activities without pain in minimal time.

Artificial disc replacement surgery is a more invasive surgery.  The intended purpose of this herniated disc surgery is to restore the disc height while also restoring the physiologic motion that a person would have with a healthy disc.  Artificial disc replacement surgery is a type of joint replacement, which will involve inserting the artificial disc into the intervertebral space.   Therefore, the original unhealthy disc will be removed so that a new artificial one can be implanted.

The artificial disk is designed to function like a joint.  It will provide motion, such as:  flexion, extension, side bending, and rotation.  It will also provide height and curvature alignment to resemble the natural disc.

Understanding the Role of a Healthy Disc within the Spine

A healthy disc acts as a spacer, a shock absorber, and a motion unit.  When the disc is functioning as a spacer, this allows motion to occur.  Spacing is important because it allows the intervertebral foramen to maintain a specific height, which will allow room for the segment nerve roots to exit without pressure.

When it acts as a shock absorber, this will allow the spine to compress and rebound while the spine is preparing for activities, such as jumping and running.  It helps to resist the downward pull of gravity on the head and trunk when a person is sitting or standing.

When acting as a motion unit, the disc’s elasticity will allow motion, so the spinal segment can flex, bend, or rotate.  It will also allow the spine to bend to the side.

Benefits and Risks of Disc Replacement Surgery for a Herniated Disc

The most obvious benefits are that the spine can move.  Another benefit is that bone graft is not required.  When a patient has spinal fusion surgery as opposed to disc replacement surgery for a herniated disc, bone graft must be taken from the hip to pack the disc space.  This will leave two incisions that will need to heal.

There are a variety of risks that can be involved in disc replacement surgery.  As with any surgery, there are risks associated with anesthesia complications, blood clots, allergic reactions, as well as adverse effects from undiagnosed medical problems.

Other risks include:

• Allergic reaction to the material of the artificial disc replacement
• Artificial disc bends, breaks, loosens, or moves
• Surgical instruments bend or break
• Infections to the wound
• Neck pain
• Arm pain
• Swallowing difficulties
• Speech problems
• Possible impairment or paralysis due to nerve or spinal cord injury
• Numbness of extremities
• Loss of motion
• Protective membrane tear
• Swelling of tissue
• Pregnancy complications
• Not able to resume to normal activities

Unfortunately, the disc replacement surgery is not always successful.  There is a chance that this surgery will not relieve the pain or could even worsen symptoms.  Also, as with any surgical procedure, death is always a risk.

Recovery from this type of surgery is not easy and will likely require some type of physical therapy.  However, in time, the pain can be substantially reduced or completely eliminated, allowing a person to go back to his/her everyday activities.

The majority of people diagnosed with a herniated disc will not have to be subjected to surgery.  Those that pass the qualifications for a surgery will be given surgical options.  The more traditional open back surgery is not as common today because of the risks involved, as well as the longer recovery time and hospitalization requirement.

The non-traumatic surgeries available for people require a less invasive incision.  Because of this, the recovery time is almost immediate and requires no hospital time.  In fact, most people will go home the same day and will only require a band-aid over the incision.

Herniated Disc – Percutaneous Endoscopic Discectomy

In this procedure, a local anesthetic is given to the patient.  A small incision will be made for a round Depuy Tube.  As the tube is inserted, the muscles will be pushed out of the way.  In a traditional surgery, these muscles would have been cut or torn.  This tube will help to prevent damage to the surrounding muscles.

A laser, camera, suction, irrigation, and other surgical instruments will be inserted through this tube.  The laser will vaporize the disc material, which will reduce pressure on the spinal cord or nerve.  Relief will generally be felt as the pressure is taken off of the nerve.   The tube will be removed, and the muscles will move back into their original place.

This herniated disc procedure will take from 30 to 45 minutes.   Recovery time is usually less than two hours. The patient will be able to leave as long as there is someone to drive him/her home.

Herniated Disc – Endoscopic Cervical and Lumbar Discectomy (Laser Spine Surgery)

Endoscopic laser spine surgery is a minimally invasive procedure that only requires a local anesthetic.   A small metal tube is inserted into the area where the herniated disc has ruptured.  With the help of an X-ray and a camera, a large piece of disc material will be vaporized with a laser.  This will kill the pain nerves inside the disc and harden the disc to prevent more leakage of the disc material.  These two types of laser spine surgery are similar, yet they do have some minor differences.   One of these differences is the size of tube that is used.  A cervical discectomy will require a 4mm in diameter tube, while a lumbar will require a 3mm in diameter tube.  Both surgeries have a high success rate and are highly recommended as opposed to the traditional open back surgery.

Herniated Disc Laser Spine Surgery Postoperative Care

The majority of the patients will feel relief from pain immediately following the procedure.  Patients are allowed to get up and walk the same day.  They can be released from the hospital within one to two hours.

Muscle relaxants may be prescribed for those who experience lower back muscle spasms.  These muscle spasms can last for a few days after the procedure.  A patient may also use heat and a light massage for these muscle spasms, if needed.

The majority of the people who are diagnosed with a herniated disc are not in need of surgery.   Only about 10% of people diagnosed with a herniated disc will need to seek surgical options to relieve their pain.    The purpose for herniated disc surgery is to decrease the pain and allow the patient to move and function as normally as possible.

A doctor will consider the following before he/she makes a decision to operate:

1. Is there still continual leg pain that has not improved over a four week period of nonsurgical treatment?
2. Do the results of the physical examination currently show there is weakness, loss of motion, or abnormal sensitivity?
3. Does the diagnostic testing from an MRI, CT or Myelogram show that there is a herniated disc that can be treated surgically?

Other factors that will be taken into consideration before a decision for surgery is made:

• Age
• Overall health
• Severity of symptoms
• The impact symptoms have on patient’s life

Traditional Open Back Surgery (Traumatic)

Traditional open back surgery is an option that is slowly becoming less and less used as technology is becoming more advanced.  However, while there are other options for surgery, they may not be as effective for a patient’s needs.  For example, the option of disc surgery is not performed if the only symptom of the herniated disc is low back pain.

Disadvantages of Traditional Open Back Surgery (Traumatic)

• High risks
• Hospitalization
• Long and painful recovery time

Non-Traumatic Herniated Disc Surgery

The non-traumatic approach to remove herniated disc material is generally an outpatient surgical procedure that only requires a local anesthesia.  A small specially designed probe is inserted between the vertebrae and into the herniated disc space through the skin.   An x-ray fluoroscopy and a magnified video are used for guidance.

Traumatic Verses Non-Traumatic Discectomy

It is obvious that the non-traumatic discectomy is what is best for the patient.  There is less recovery time in a non-traumatic surgery because the incision is not as invasive.  There are no stitches needed.  After the probe is taken out, a band-aid will be placed over the incision.

In a non-traumatic discectomy, there is no bone removal or back muscle dissection.   The risk of complications is reduced dramatically.  There is less of a chance for scarring, blood loss, infection, and anesthesia related risks in a non-traumatic discectomy than in a traumatic discectomy.

Types of Non-Traumatic Discectomy

There are a variety of different non-traumatic herniated disc surgeries.  Many different doctors will offer different types of non-traumatic herniated disc surgeries.  They are considered non-traumatic as they do not require hospitalization and they are minimally invasive and have fewer risks than open discectomy.   There is the laser spine surgery and the Lumbar Endoscopic Discectomy, as well as the very common Percutaneous Endoscopic Discectomy.

It is recommended that a person research all options.  However, the non-traumatic has proven to be the best route to take.   Technology advances have made it possible for patients to endure herniated disc surgery without severe pain.  Check into all the options before making a decision.

The lumbar section of the back is where the majority of herniated discs will occur.  The lumbar segments of the back are located in the lower back.  A lumbar herniated disc occurs when the inner gel-like material leaks out of the outer core.  A herniated disc in the lumbar section of the spine can put pressure on the spinal nerve root.  This will cause sciatica, which is pain that can shoot down the leg.

Nearly 90% of herniated disc in the lumbar area will occur at the bottom of the spine.  The spine is described in segments.  Most herniated discs occur in lumbar segments 4 and 5 (L4-L5), which will cause pain in the L5 nerve, or lumbar segment 5 and sacral segment 1 (L5-S1), which will cause pain in the S1 nerve.   Symptoms will depend on where the herniated disc is located within the Lumbar segments.

Symptoms for L5 Nerve Impingement

A herniated disc at this location can cause weakness when extending the big toe.  This weakness can run up into the ankle.  The top of the foot can experience numbness and pain.  Radiating pain can shoot up into the buttocks.

Symptoms for S1 Nerve Impingement

A herniated disc at this location can cause loss of ankle reflex.  It can also cause weakness in an ankle push off.  The patient is not able to do toe rises.  Pain and numbness can radiate down the leg to the sole of the foot or outside of the foot (Sciatica).

Sciatica and the Herniated Disc

It is important to understand that sciatica is a symptom, not a diagnosis.  Sciatica is a symptom of a herniated disc that has put pressure on the radiuclar nerve in the lower back.  The clinical diagnosis for a herniated disc protrusion that causes the sciatic symptom is called “radiculopathy”.   When pressure is put on this nerve from a herniated disc, leg pain can occur along with tingling, numbness, or weakness that will begin in the lower back and travel through the buttocks and down the large sciatic nerve in the back of the leg.

The symptom sciatica can be very painful and even debilitating.  However, while it can be extremely painful, it is not commonly known to cause permanent sciatic nerve damage.  Because the spinal cord is not located in the lower spine, a herniated disc in this area will not generally pose a paralysis threat.

Cauda Equina Syndrome

The conus medullaris is formed just below the spinal cord and near the first lumbar vertebra.  Just below the conus medullaris is a bundle of nerve roots called the cauda equina.   Cauda Equina Syndrome is a rare condition that can be caused by compression or inflammation of the nerve roots.

There are two sciatica symptoms to watch for in order to determine if the Cauda Equina Syndrome is present.   It is important to seek emergency medical care in the event that the weakness in the leg becomes progressive and if bladder or bowel incontinence or dysfunction occurs.

Symptoms of the lumbar herniated disc can possibly be relieved within 4 to 6 weeks with nonsurgical treatments.  If after this time there is still pain, surgical options may be discussed.

The thoracic herniated disc is located in the upper back.   Thoracic herniated discs are not as common as the lumbar or cervical herniated disc.  This is because there is generally less pressure and motion in this segment of the spine.

A thoracic herniated disc occurs when the inner gel-like substance of any of the 12 vertebral discs of the thoracic spine leaks out of the inside of the disc.  This puts pressure on a nerve root that creates upper back pain along with other symptoms, such as shooting pain or numbness.    The type of pain caused will depend on which nerve is receiving this pressure.  It will also depend on if the spinal cord itself has pressure being placed on it.

It is important to determine the cause of the thoracic herniated disc before treatment of upper back pain.  There are two sources that doctors will look at to determine which course of treatment to take.  These causes are classified as:

• Degenerative Disc Disease – Degenerative is associated with a slow and gradual wear and tear of the vertebral discs.   This is generally caused with age.   It is a very slow process, and patients will usually not feel the effects of the wearing and tearing until long after the onset of the degeneration.    Degenerative disc disease will generally be seen in people in their 40’s and 60’s.
• Thoracic Segment Trauma – When a trauma has occurred to the thoracic region of the back, a herniated disc can develop.   Symptoms will develop upon impact.   A fall or sports injury causing sudden force to the upper back could be a traumatic event that could lead to a thoracic herniated disc.    Younger patients can be exposed to a thoracic segment trauma herniated disc.

Symptoms Associated with the Thoracic Herniated Disc

The symptoms of a thoracic herniated disc will depend on the size and location of the herniated part of the disc.  There are general areas that a herniated disc can erupt, which are:  central, lateral, or centro-lateral.   The symptoms for each are as follows:

• Central Disc Protrusion – There is not much room under the spinal cord in the thoracic spine.  Therefore, when there is pressure from the thoracic herniated disc, pressure is put on the spinal cord and can affect this nerve.  This type of herniated disc will cause upper back pain.  It will depend on the size of the herniated disc and the amount of the pressure on the spinal cord as to the extent of the symptoms.  In severe cases, paralysis from the waist down could be a result.
• Herniated Lateral Disc – If a disc protrudes laterally, this is to the side.  The gel-like material will put pressure on the nerve that is located at that level of the spine and will likely cause radiation chest wall or abdominal pain.
• Herniated Centro-lateral Disc – A combination of symptoms can occur with this type of thoracic herniated disc.  This could be upper back pain, radiating pain, or Myelopathy, which is a functional disturbance or pathological change in the spinal cord.

While the thoracic herniated disc is not as common as the others, it still exists and can be painful.  It is important that the type of herniated disc is discovered to ensure proper treatment.

A herniated disc could be the cause of mild to severe back pain.  The first step in determining the cause of back pain is to contact a doctor.  At this point, a doctor will perform an initial exam that will consist of a medical history and physical exam.

Initial Exam

After the medical history and physical exam are performed, a diagnosis of a possible herniated disc will be considered if there is irritation of one or more spinal nerves.   In this initial exam, if there is any loss of strength, sensation, or reflexes, the doctor will likely begin further investigation into determining if there is a herniated disc.  At this point, further tests and visits will be scheduled.  There will likely not be any more tests done during this visit.

Tests to Confirm a Herniated Disc

Imaging tests are used to confirm a herniated disc.   These tests are generally not performed unless nonsurgical treatments do not work to relieve the pain.  If there is still pain after four weeks of nonsurgical treatment, imaging tests will likely be recommended.   If the doctor is sure there is a herniated disc, these tests may not be needed.

Imaging Tests include:

• Magnetic Resonance Imaging (MRI) – This will confirm and show the location and severity of the herniated disc.  At this time, a doctor will look to make sure there is not some other serious condition, such an infection or tumor.   The images detailed in an MRI are of the soft tissues of the spine.  These soft tissues include:  muscles, spinal nerves, tendons, ligaments, discs, and marrow (the soft inner part of the bones of the spine).
• Computed Tomography (CT) Scan – This test will confirm and show the location and severity of the herniated disc, as well.  It can also look for other problems in the bones of the spine.  It can show detailed images of the bony structures of the spine.  This test is generally done if a person cannot have an MRI done.  For example, a person with a pacemaker cannot have an MRI performed.  It can also be performed if the results of an MRI are inconclusive.

For diagnosing a herniated disc in the lumbar spine (lower back), an MRI is preferred over a CT scan.  X-rays are not generally useful for diagnosing a herniated disc; however, a doctor may decide to have an X-ray or blood test done if there is no change in the pain after four weeks of nonsurgical treatment to rule out any other possibilities.

Other Test Options

The following tests can help to diagnose a herniated disc; however, they are not used as often for a herniated disc.  They could give the doctor more detailed information, if needed.

• Electromyogram and Nerve Conduction Test – Used to diagnose nerve and muscle disorder that could be performed on people who show signs of prolonged pressure on the nerve root.
• Myelogram – This is an X-ray of the spinal canal where a dye will outline the space of the spinal cord.  This test is combined with a CT scan and can be used if an MRI is not possible.
• Discography – In this test, a dye is injected into the gel-like center of the spinal disc to help diagnose disc problems.
• Nerve Root Block – A local anesthesia is injected next to the spinal nerve to confirm which nerve is being affected.

Once a doctor is certain of the diagnosis of a herniated disc, proper treatment options can be discussed.

Herniated discs are generally caused by wear and tear of the disc.  When a person ages, the vertebral disc will lose some of the fluid that helps keep the spine flexible.   Herniated discs are also caused by injuries to the spine.  This injury could cause tiny tears or cracks on the outer layer (Annulus Fibrosus).  The inner layer with the gel-like substance is forced though the tears or cracks causing the disc to bulge, rupture, or break into pieces.

Causes of Injury to the Spine

There are many activities or accidents that can cause an injury to the spine.   When there is sudden heavy strain or an increase of pressure to the lower back, a herniated disc can become worse.  Sudden twisting or even forceful sneezing can force the gel-like substance through the disc’s outer layer.

Repetitive activities that are stressful to the lower back can cause an aggravated disc to rupture.  This could include poor lifting habits, vibration exposure over time, or injuries from sports.

Herniated Disc Risk Factors

There are a variety of risk factors, some of which cannot be changed.  However, some risk factors could be prevented by simple changes.  Risk factors that cannot be changed are:

• Age
• Gender
• History

As mentioned above, age is a contributing factor to herniated discs.  Males are more prone to herniated discs.  The history of a person’s injuries to the back, previous herniated discs, and back surgery cannot be changed.

There are some risk factors that can be changed.  Taking the steps to reduce the risk from these factors can decrease a person’s overall risk of developing a herniated disc.  Lifestyle change and/or medical treatment could significantly decrease these risks.

Risk factors that can be changed:

• Job and Activities – Jobs or activities that can increase the risk of a herniated disc entail long periods of sitting or pulling heavy objects, frequent bending or twisting of the back, heavy physical exertion, repetitive back movement or an exposure to constant vibration.
• Strenuous Exercise – Strenuous exercise for a long period of time or exercising too hard after a long period of inactivity can increase the risk of a herniated disc.  Also, not exercising on a regular basis could increase the risk of a herniated disc.
• Smoking – Toxins found in Nicotine can keep the spinal discs from absorbing nutrients they need from the blood.  Smoking can also increase the sensitivity to pain.
• Overweight – Extra weight can put added strain on the lower back.

Herniated Disc Prevention Steps

The above risk factors can be decreased by taking the necessary prevention steps.    They are simple and can change a person’s risk of a herniated disc significantly.

• Maintain a healthy body weight.
• Exercise on a regular basis.
• Stop smoking.
• Use proper lifting techniques.
• Practice good posture.

Tips for Perfect Posture

• When standing or walking, keep shoulders back and down, chin down, abdomen in, and lower back supported.
• When sitting, use a small pillow or rolled towel to help support the lower back.
• When sleeping, keep back in a neutral position.  Use a towel roll to support the lower back or place a pillow under the knees.

Proper lifting techniques are important.  Lift by squatting and bending the knees.  Use the legs to push up.  Prevention is the key to lowering the risks of a herniated disc.