Lumbar Disc Herniation

What is Disc Herniation?

Herniation of a disc means that its jelly-like nucleus pushes and enters the outer ring (annulus pulposis) due to wear and tear or a sudden injury. This pressure against the outer ring causes lower back pain. However, with more herniation of the nucleus, the spinal nerves are compressed and irritated giving rise to Sciatica or leg pain. Pressure on these sensitive spinal nerves may cause pain, numbness, or weakness in one or both legs. Lumbar discs, especially the L4-5 and L5-S1 discs are subjected to maximum load as they are at the lowermost part of the spine.

Why does herniation/prolapsed disc happen?

Most commonly, a herniated disk is related to the natural aging of your spine, called as degenerative disc disease. In children and young adults, disks have high water content. With age the disks begin to dry out and weaken and this process starts as early as 20 years of age! As the nucleus ages, stresses are distributed unevenly on the annulus. Also cracks appear in the Annulus which allows the nucleus to escape when the disc is subjected to high pressure giving rise to Herniation.

Are there risk factors for disc herniation?

In addition to the gradual wear and tear that comes with aging, other factors can increase the likelihood of a herniated disk. Knowing what puts you at risk for a herniated disk can help you prevent further problems.

Most common cause for herniated disc is Improper/ sudden lifting of weight. Bending forward to lift heavy objects, instead of sitting on legs and gradually lifting, twisting while you lift or lifting weights in a HURRY can cause a herniated disk. Being overweight and having pendulous abdomen puts added stress on the disks in your lower back.

Other factors predictive for disc herniation include tall men, heavy women, individuals with a small spinal canal, and those who work in an environment with considerable vibration, such as heavy equipment operators. It is believed that smoking lessens oxygen supply to the disk and causes more degeneration. Regular exercise is important in preventing many medical conditions, including a herniated disk.

Investigations: You may not need any investigations if your symptoms resolve in a week or two. Once your doctor has examined you, he/she may order for a few investigations to confirm the diagnosis.

X-ray of the spine shows the structure of the vertebrae and the outline of the joints and helps to search for other potential causes of pain, i.e. tumors, infections, fractures, etc.

Magnetic resonance imaging (MRI): This is the mainstay for diagnosis for Herniated disc. It shows three-dimensional images of body structures using powerful magnets and computer technology including the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. No ionizing radiation is used during MRI, so it carries no risk of radiation exposure.

Electromyogram and Nerve Conduction Studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression.

Treatment

Lumbar disc herniation has a very favorable natural history i.e the patients improve without much intervention. 80% of the patients improve in six weeks and 90%, after twelve weeks1. Also the majority of disc herniations seen on MRI diminish in size over time, with 80% decreasing by >50% in 6-12months1.

Therefore nonoperative treatment is the initial "default" pathway for the majority of patients with lumbar radiculopathy due to disc herniation2,3.(Evidence Based Practice)

Non-operative treatment

Bed rest: No more than 1–2 days of rest is advised (EVIDENCE BASED PRACTICE5) and you are encouraged to move around in the house as much as your back allows. Take rest breaks during the day, but avoid sitting for long periods of time. Make all your movements slow and controlled. Change your daily activities so that you avoid movements that can cause further pain, especially bending forward and lifting.

Traction: It may be beneficial as a method of enforced rest for a day or two, but research shows that "traction is not effective" (EVIDENCE BASED PRACTICE6) in the treatment of herniated disc.

Bracing/Lumbar supports: There is very "limited" evidence favoring lumbar supports compared with no treatment (EVIDENCE BASED PRACTICE7). It may be useful during journeys to avoid sudden jerks. Prolonged brace wear may decrease your muscle strength and may cause more problems to your spine

Exercise regimens: Your physiotherapist will guide you with specific excercises suitable for your condition. The bottom-line is not to do any exercise that aggravates your pain. Gradually your muscles of the back and abdomen are built up to protect your spine from further injury. A good exercise practiced regularly is the best way to prevent all problems related to degenerative spine.

Epidural steroid injections: In this procedure, steroids are injected into your back to reduce local inflammation. Of the above measures, only epidural injections have been proven effective at reducing symptoms. There is good evidence that epidural injections can be successful in 42-56% of patients who have not been helped by 6 weeks or more of other nonsurgical care (EVIDENCE BASED PRACTICE8).

Surgery for lumbar herniated disk.

Patients with sciatica, who undergo surgery, have better and more rapid pain relief4. Surgery resolves symptoms faster for those with motor weakness or numbness, as well. However, Research shows that patients undergoing surgery have the same results as patients treated nonsurgically2 after 2 years.

Therefore, Surgery is indicated when there is failure to respond to 4wks of good conservative management or there is progressive or fresh weakness in the affected nerve distribution, or cauda equine syndrome (Separate section).

Operative procedures

Discectomy involves removing the herniated part of the disk and any fragments that are putting pressure on the spinal nerve

  • Open discectomy – (Fenestration/Laminotomy) – It involves removal of minimal amount of bone from your lamina to reach the disc and remove the herniated fragment compressing the nerves.
  • Open discectomy – (Fenestration/Laminotomy) – It involves removal of minimal amount of bone from your lamina to reach the disc and remove the herniated fragment compressing the nerves.

EVIDENCE: Research has shown good-to-excellent clinical results in 90% of patients with Microscopic Discectomy9,10. The complication rate of dural tears, discitis, or root injury is less than 2%, and hence it has been called as the 'gold standard' procedure in the surgical management of lumbar disc herniation9. One of the reputed article9 states that..

"Lumbar microdiscectomy remains the gold standard with which all other discectomy techniques must be compared".
Microdiscectomy is the standard surgical treatment offered to patients with disc herniation, requiring surgery, at our clinic.

The risk of surgical complications is very low. Possible complications include:

  • Nerve damage
  • Dural leak — An opening of the thin lining of the nerve root canal may cause loss of the watery liquid (cerebrospinal fluid) that bathes the nerves roots. When seen during surgery, the lining may be repaired. Sometimes headaches occur afterward, but typically improve with time.
  • Hematoma causing nerve compression — This is caused by blood collecting around the nerve roots after the surgery

Recently a lot of minimally invasive surgeries have been described, but all of them have results at best comparable to microdiscectomy or inferior to it.

Minimally invasive procedures:

  • Micro-Endoscopic Discectomy (MED) – Uses tubes to reach the disc herniation along with endoscope for good vision.
  • Percutaneous endoscopic Lumbar discectomy – PELD: This uses endoscope to reach the herniated disc, more from the sides to relieve pressure on the nerve.
  • The above two procedures now are giving results close to that of microdiscectomy.
    There are many other procedures done under local anaesthesia using intraoperative x-rays to reach the herniated disc and decrease its size by various methods. These are also called as  Intradiscal Procedures or Percutaneous Disc decompression procedures or C-arm guided  “blind procedures” as the surgeon does not have actual vision of the herniated disc. The results of these procedures does not match microdiscectomy, however they are less invasive and new appliances and techniques continue to evolve in search of an ideal solution
  • Chemonucleosis – This is of historical importance where a chemical called Chemopapain was used to dissolve the disc material
  • Percutaneous Manual Disc Decompression/Automated Percutaneous Disc Decompression (APDD) – Removes disc material using specialized instruments.
  • Percutaneous Laser Disc Decompression (PLDD) – decreases the size of the disc nucleus using laser.
  • Disc nucleoplasty using radiofrequency Coblation - decreases the size of the disc nucleus using radiofrequency Coblation.
  • Intradiscal Ozone therapy - decreases the size of the disc nucleus using a OZONE.
  • Intradiscal electrothermal annuloplasty(IDET) – Burns the annulus and seals the cracks which is supposed to prevent the nucleus herniation and relieves pain by burning the nerves.
References and EVIDENCE based reviews
  • Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively.Spine . 1990;15:683 -6.
  • James N. Weinstein; Tor D. Tosteson; Jon D. Lurie; et al: Surgical vs Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial; JAMA. 2006;296(20):2441-2450 (doi:10.1001/jama.296.20.2441)
    http://jama.ama-assn.org/cgi/content/full/296/20/2441 .
  • John M. Rhee, Michael Schaufele, and William A. Abdu. Radiculopathy and the Herniated Lumbar Disc. Controversies Regarding Pathophysiology and Management J. Bone Joint Surg. Am., Sep 2006; 88: 2070 – 2080
  • Surgical Interventions for Lumbar Disc Prolapse: Updated Cochrane Review: J. N. Alastair Gibson, MD, FRCS, and Gordon Waddell, DSc, MD, FRCS. Spine • Volume 32 • Number 16 • 2007; pp 1735–1747.
  • Hagen KB, et al The Cochrane review of bed rest for acute low back pain and sciatica. Spine. 2000;25:2932-9.
  • Clarke JA, et al Traction for lowback pain with or without sciatica. Cochrane Database Syst Rev. 2005;4: CD003010.
  • Van Tulder MW, et al Lumbar supports for prevention and treatment of low back pain.Cochrane Database Syst Rev. 2000;3:CD001823.
  • Schaufele Met al, Arch Phys Med Rehabil. 2002;83:1661; Vad VB, et al Spine.2002;27:11-6.
  • Apostolides PJ, Jacobowitz R, Sonntag VK.: Lumbar discectomy microdiscectomy: "the gold standard". Clin Neurosurg. 1996;43:228-38. Review.
  • Koebbe CJ, Maroon JC, Abla A, El-Kadi H, Bost J. Lumbar microdiscectomy: a historical perspective and current technical considerations. Neurosurg Focus. 2002 Aug 15;13(2):E3.
Meet Our team
Dr. Mahesh B.H

M.S (Ortho) AIIMS
New Delhi
Spine Surgeon

Dr. Upendra B.N

M.S (Ortho) AIIMS
New Delhi
Spine Surgeon

Dr Raghavendra Rao D

MS Ortho, AFSA Spine(France)
Spine Surgeon

Dr. Vijay S

MS (Ortho)
Fellowship in Spine Surgery
(CMC, Vellore)
Spine Surgeon

Dr. Anand Jayaraman

M.B.B.S MRC Psych (UK)
Consultant Psychiatrist
(Pain Management)

Dr. Arun Kumar G.C

MS (Ortho)
Spine Registrar

Dr Vinay Jain K

MS (Ortho)
Spine Registrar

Mrs. Leena

Secretary & Co-ordinator

Mr. Gangadhar A.S

Co-ordinator