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Herniated lumbar disc HLD

herniated lumbar disc

Overview
A herniated dis c is a spine condition that occurs when the gel-like center of a dis c ruptures through a weak area in
the tough outer wall, sim ilar to the filling being squeezed out of a jelly doughnut. Low back or leg pain m ay res ult
when the dis c m aterial touches or com presses a nearby spinal nerve. Conservative nonsurgical treatm ent is the
firs t step to recovery. With a team approach to treatm ent, 80% of people im prove in about 6 weeks and return to
norm al activity. If you dont respond to cons ervative treatm ent, your doctor m ay recom m end surgery.

Anatomy of the intervertebral discs

To unders tand a herniated dis c, it is helpful to unders tand a little about how your spine works. Your s pine is m ade
of 24 m oveable bones called vertebrae. The lum bar (lower back) s ection of the spine bears m ost of the weight of
the body. There are 5 lum bar vertebrae num bered L1 to L5. The vertebrae are separated by cushiony discs, which
act as s hock abs orbers preventing the vertebrae from rubbing together. The outer ring of the disc is called the
annulus . It has fibrous bands that attach between the bodies of each vertebra. Each disc has a gel-filled center
called the nucleus . At each disc level, a pair of spinal nerves exit from the spinal cord and branch out to your body.
Your spinal cord and the s pinal nerves act as a "telephone," allowing m es sages, or im pulses , to travel back and
forth between your brain and body to relay sens ation and control m ovem ent (see Anatom y of the Spine).

What is a herniated lumbar disc?

Mayfield services
At Mayfield, patients who com e to us with neck and
back problem s are given a rapid review of their
m edical condition within a few days ... not weeks.
It's a treatm ent process called Priority Consult.
Nearly 80% of our spine patients are able to
recover with nons urgical treatm ent. But when
physical therapy, m edications, and s pinal injections
fail to relieve back or leg pain, we help patients with
surgery.
We treat m ore than 2,250 patients with herniated
lum bar disc problem s each year.
To m ake an appointm ent, call 513-221-1100.

A herniated dis c occurs when the gel-like center of your dis c ruptures out through a tear in the tough disc wall
(annulus ) (Fig. 1). The gel m aterial is irritating to your spinal nerves, caus ing som ething like a chem ical irritation.
The pain is a res ult of s pinal nerve inflam m ation and swelling caus ed by the pressure of the herniated disc. Over
tim e, the herniation tends to s hrink and you m ay experience partial or com plete pain relief. In m ost cases, if low
back and/or leg pain is going to resolve it will do s o in about 6 weeks.

Brad grew up with back pain from an early age. By

the tim e he had reached college, the pain was
unbearable. View Brad's story >

Figure 1. A he rniate d disc occurs whe n the ge l-fille d nucle us mate rial e scape s
through a te ar in the disc annulus and compre sse s the spinal ne rv e .
Different term s m ay be used to describe a herniated dis c. A bulging disc (protrus ion) occurs when the dis c annulus
rem ains intact, but form s an outpouching that can press agains t the nerves. A true herniated disc (also called a
ruptured or s lipped disc) occurs when the disc annulus cracks or ruptures , allowing the gel-filled center to squeeze
out. Som etim es the herniation is s o severe that a free fragm ent occurs, m eaning a piece has broken com pletely
free from the dis c and is in the s pinal canal.

Marialice's story

Most herniated dis cs occur in the lum bar section of the s pine, where nerves from the s pinal cord exit between the
lum bar vertebrae, and then join together again to form the sciatic nerve, which runs down your leg.

What are the symptoms?

Sym ptom s of a herniated disc vary greatly depending on the location of the herniation and your own respons e to
pain. If you have a herniated lum bar disc, you m ay feel pain that radiates from your low back area, down one or
both legs , and s om etim es into your feet (called sciatica). You m ay feel a pain like an electric shock that is severe
whether you stand, walk, or s it. Activity such as bending, lifting, twisting, and s itting m ay increase the pain. Lying flat
on your back with knees bent m ay be the m os t com fortable becaus e it relieves the downward press ure on the disc.

Thomas's story

Som etim es the pain is accom panied by num bness and tingling in your leg or foot. You m ay experience cram ping
or m uscle s pas m s in your back or leg.
In addition to pain, you m ay have leg m uscle weakness , or knee or ankle reflex loss . In severe cases , you m ay
experience foot drop (your foot flops when you walk) or los s of bowel or bladder control. If you experience extrem e
leg weaknes s or difficulty controlling bladder or bowel function, you s hould seek m edical help im m ediately.

What are the causes?

Dis cs can bulge or herniate becaus e of injury and im proper lifting or can occur s pontaneous ly. Aging plays an
im portant role. As you get older, your dis cs dry out and becom e harder. The tough fibrous outer wall of the disc
m ay weaken, and it m ay no longer be able to contain the gel-like nucleus in the center. This m aterial m ay bulge or

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rupture through a tear in the disc wall, caus ing pain when it touches a nerve. Genetics, s m oking, and a num ber of
occupational and recreational activities m ay lead to early dis c degeneration.

Who is affected?
Herniated discs are m ost com m on in people in their 30s and 40s , although m iddle aged and older people are
slightly m ore at ris k if they're involved in strenuous physical activity.
Lum bar dis c herniation is one of the m ost com m on caus es of lower back pain ass ociated with leg pain, and
occurs 15 tim es m ore often than cervical (neck) dis c herniation. Dis c herniation occurs 8% of the tim e in the
cervical (neck) region and only 1 to 2% of the tim e in the upper-to-m id-back (thoracic) region [1].

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Click here for information about clinical trials
conducted by our doctors at local Cincinnati
hospitals or call 1-800-325-7787.

How is a diagnosis made?

When you first experience pain, consult your fam ily doctor. Your doctor will take a com plete m edical history to
understand your s ym ptom s , any prior injuries or conditions , and determ ine if any lifestyle habits are caus ing the
pain. Next a phys ical exam is perform ed to determ ine the s ource of the pain and tes t for any m us cle weakness or
num bnes s.
Your doctor m ay order one or m ore of the following im aging studies : X-ray, MRI scan, m yelogram , CT s can, or EMG.
Bas ed on the results, you m ay be referred to a neurologist, orthopedis t, or neuros urgeon for treatm ent.
Magnetic Resonance Imaging (MRI) scan is a noninvas ive tes t that uses a m agnetic field and
radiofrequency waves to give a detailed view of the s oft tis sues of your spine. Unlike an X-ray, nerves
and dis cs are clearly vis ible (Fig. 2). It allows your doctor to view your spine 3-dim ensionally in s lices ,
as if it were s liced layer-by-layer like a loaf of bread with a picture taken of each slice. The pictures
can be taken from the s ide or from the top as a cros s -s ection. It m ay or m ay not be perform ed with a
dye (contrast agent) injected into your bloods tream . An MRI can detect which dis c is dam aged and if
there is any nerve com pres s ion. It can also detect bony overgrowth, spinal cord tum ors , or
absces s es .

Figure 2. M RI image and illustration show a disc he rniation be twe e n

the L5 v e rte bra and the sacrum. On M RI he althy discs appe ar white
and plump, while de ge ne rativ e , drie d out discs appe ar grayish and
flatte ne d.
Myelogram is a s pecialized X-ray where dye is injected into the s pinal canal through a s pinal tap. An
X-ray fluoroscope then records the im ages form ed by the dye. Myelogram s can show a nerve being
pinched by a herniated dis c, bony overgrowth, s pinal cord tum ors, and abscess es . Regular X-rays of
the s pine only give a clear picture of bones. The dye us ed in a m yelogram s hows up white on the Xray, allowing the doctor to view the s pinal cord and canal in detail. A CT scan m ay follow this test.
Computed Tomography (CT) scan is a safe, noninvas ive tes t that uses an X-ray beam and a
com puter to m ake 2-dim ens ional im ages of your s pine. Sim ilar to an MRI, it allows your doctor to
view your s pine in slices , as if it were s liced layer-by-layer with a picture taken of each s lice. It m ay or
m ay not be perform ed with a dye (contras t agent) injected into your bloodstream . This test is
es pecially us eful for confirm ing which dis c is dam aged.
Electromyography (EMG) & Nerve Conduction Velocity (NVC) tests. EMG m easures your m us cle
response to electrical s tim ulation. Sm all needles are placed in your m uscles, and the results are
recorded on a special m achine. NCV is s im ilar, but it m eas ures how well your nerves pass an
electrical signal from one end of the nerve to another. Thes e tes ts can detect nerve dam age and
m us cle weaknes s.
X-ray tests us e X-rays to view the bony vertebrae in your s pine and can tell your doctor if any of them
are too close together or whether you have arthritic changes , bone s purs, or fractures . It's not
poss ible to diagnos e a herniated dis c with this tes t alone.

What treatments are available?

Cons ervative nonsurgical treatm ent is the first step to recovery and m ay include m edication, rest, phys ical therapy,
hom e exercis es , hydrotherapy, epidural steroid injections (ESI), chiropractic m anipulation, and pain m anagem ent.
With a team approach to treatm ent, 80% of people with back pain im prove in about 6 weeks and return to norm al
activity. If you dont respond to cons ervative treatm ent, your doctor m ay recom m end surgery.
Nonsurgical treatments
Self care: In m ost cas es , the pain from a herniated disc will get better within a couple days and com pletely resolve
in 4 to 6 weeks . Restricting your activity, ice/heat therapy, and taking over the counter m edications will help your
recovery.

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Medication: Your doctor m ay pres cribe pain relievers , nons teroidal anti-inflam m atory m edications (NSAIDs), m us cle
relaxants , and s teroids.
Nons teroidal anti-inflam m atory drugs (NSAIDs ) (NSAIDs), s uch as aspirin, naproxen (Alleve,
Napros yn), ibuprofen (Motrin, Nuprin, Advil), and celecoxib (Celebrex), are used to reduce inflam m ation
and relieve pain.
Analges ics, such as acetam inophen (Tylenol), can relieve pain but dont have the anti-inflam m atory
effects of NSAIDs. Long-term us e of analges ics and NSAIDs m ay cause s tom ach ulcers as well as
kidney and liver problem s.
Mus cle relaxants , s uch as m ethocarbam ol (Robaxin), caris oprodol (Som a) and cyclobenzaprine
(Flexeril), m ay be pres cribed to control m us cle s pas m s .
Steroids m ay be pres cribed to reduce the swelling and inflam m ation of the nerves . They are taken
orally (as a Medrol dose pack) in a tapering dos age over a five-day period. It has the advantage of
providing alm ost im m ediate pain relief within a 24-hour period.
Steroid injections into the area of your herniated dis c m ay be prescribed if your pain is s evere (s ee
Epidural Steroid Injections ). This procedure, perform ed under fluoros copy, involves an injection of
s teroids and an analges ic num bing agent into the epidural s pace of the spine to reduce the s welling
and inflam m ation of the nerves . About 50% of patients will notice relief after an epidural injection,
although the res ults tend to be tem porary. Repeat injections , at 2-week intervals, m ay be neces sary to
obtain the bes t res ults in the shortes t tim e. If the injection is helpful, it can be done up to three tim es
a year.
Physical therapy: The goal of phys ical therapy is to help you return to full activity as s oon as pos s ible and prevent
re-injury. Phys ical therapists can instruct you on proper pos ture, lifting, and walking techniques , and theyll work
with you to strengthen your lower back, leg, and s tom ach m uscles . Theyll also encourage you to stretch and
increas e the flexibility of your s pine and legs . Exercise and s trengthening exercis es are key elem ents to your
treatm ent and s hould becom e part of your life-long fitnes s .
Holistic therapies: Som e patients want to try holis tic therapies s uch as acupuncture, acupres sure, nutritional
supplem ents , and biofeedback. The effectivenes s of thes e treatm ents for a herniated disc m ay help you learn
coping m echanism s for m anaging pain as well as im proving your overall health. For res ources in your area vis it.
Surgical treatments
Surgery for a herniated lum bar dis c, called a dis cectom y, m ay be an option if your sym ptom s do not s ignificantly
im prove with cons ervative treatm ents. Surgery m ay als o be recom m ended if you have s igns of nerve dam age, s uch
as weakness or loss of feeling in your legs .
Microsurgical discectomy: The s urgeon m akes a 12 inch incis ion in the m iddle of your back. To reach the
dam aged disc, the s pinal m uscles are dis s ected and m oved aside to expos e the vertebra. A portion of the bone is
rem oved to expos e the nerve root and disc. The portion of the ruptured dis c that touches your s pinal nerve is
carefully rem oved us ing s pecial instrum ents . About 8085% of patients s ucces sfully recover from a dis cectom y and
are able to return to their norm al job in approxim ately 6 weeks [2].
Minimally invasive microendoscopic discectomy: The surgeon m akes a tiny incision in the back. Sm all tubes
called dilators are us ed with increas ing diam eter to enlarge a tunnel to the vertebra. A portion of the bone is
rem oved to expos e the nerve root and disc. The s urgeon us es either an endoscope or a m icros cope to rem ove the
ruptured dis c. This technique caus es less m us cle injury than a traditional discectom y.
Clinical trials
Clinical trials are res earch s tudies in which new treatm ents drugs , diagnos tics, procedures , and other therapies
are tested in people to see if they are s afe and effective. Res earch is always being conducted to im prove the
standard of m edical care. Inform ation about current clinical trials , including their eligibility, protocol, and locations
are found on the web. Studies can be s pons ored by The National Institutes of Health (NIH), clinicaltrials .gov, as
well as private industry and pharm aceutical com panies , www.centerwatch.com .

Recovery & prevention

Back pain affects 8 of 10 people at s om e tim e in their lives , and us ually resolves within 6 weeks. A positive m ental
attitude, regular activity, and a prom pt return to work are all very im portant elem ents of recovery. If your regular job
cannot be done initially, it is in the patient's bes t interes t to return to som e kind of m odified (light or restricted) duty.
Your phys ician can give pres criptions for s uch activity for lim ited periods of tim e.
The key to avoiding recurrence is prevention:
Proper lifting techniques (see Self Care for Neck & Back Pain)
Good posture during s itting, s tanding, m oving, and s leeping (s ee Pos ture for a Healthy Back)
Appropriate exercis e program to s trengthen weak abdom inal m us cles and prevent re-injury (s ee
Exercis e for a Healthy Back)
An ergonom ic work area
Healthy weight and lean body m ass
A positive attitude and s tres s m anagem ent
No s m oking

Sources & links

If you have m ore ques tions, pleas e contact the Mayfield Clinic & Spine Institute at 800-325-7787 or 513-221-1100.
Links
www.s pine-health.com
www.s pineunivers e.com
www.neuros urgerytoday.org/what/patient_e/herniated.as p
Sources
1.

MedlinePlus Medical Encyclopedia

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2.

Herniated lumbar disc HLD

Am erican As s ociation of Neurological Surgeons and the Congres s of Neurological Surgeons

Glossary
annulus (annulus fibrosis ): tough fibrous outer wall of an intervertebral disc.
disc (intervertebral dis c): a fibrocartilagenous cus hion that s eparates s pinal vertebrae. Has two parts , a s oft gel-like
center called the nucleus and a tough fibrous outer wall called the annulus.
foramen (intervertebral foram en): the opening or window between the vertebrae through which the nerve roots leave
the s pinal canal.
nucleus (nucleus pulposus ): s oft gel-like center of an intervertebral dis c.
sciatica: pain that courses along the s ciatic nerve in the buttocks and down the legs. Usually caused by
com pres sion of the fifth lum bar spinal nerve.
vertebra: (plural vertebrae): one of 33 bones that form the s pinal colum n, they are divided into 7 cervical, 12
thoracic, 5 lum bar, 5 sacral, and 4 coccygeal. Only the top 24 bones are m oveable.
updated > 3.2013
reviewed by > Robert Bohins ki, MD, Mayfield Clinic / Univers ity of Cincinnati Departm ent of Neuros urgery, Cincinnati,
Ohio
Mayfield Certified Health Info m aterials are written and developed by the Mayfield Clinic & Spine
Institute. We com ply with the HONcode s tandard for trus tworthy health inform ation. This inform ation
is not intended to replace the m edical advice of your health care provider.

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