"Herniated Lumbar Disc" is usually a painful condition for which
patients request assistance. It is essential to recognize that most
patients can and do recover very satisfactorily from this experience
without resorting to surgical intervention. The term commonly used for
this non-surgical therapy is "CONSERVATIVE TREATMENT." It is an
"active" form of treatment, which requires consummate self-discipline
and patience since the tissues involved in this disease process heal
very, very slowly.
Hopefully when you have a better understanding of the underlying
disease process and the pathological anatomy you will recognize the
course of therapy that is best suited for you. There are some
anatomical diagrams in the back of this booklet that should assist
you in comprehending the text that follows.
Disc material is "rubbery" in consistency. The disc acts as a "shock
absorber" between each Vertebral Body and lies in front of the
Spinal Canal. The disc is part of a multiple joint system at
each level of the Spinal Column. The degree of motion at each
spinal level is determined by a number of factors including the size,
shape and angle of the interdigitating joints (Facet Joints) between
each vertebra as well as the strength of the ligaments and muscles
that join one vertebra to the next. The disc itself is also part
of this system that changes over time as we age.
Each disc has several components. The center region
(Nucleus Pulposus) is more viscous. A multilayered and very
dense capsule (Annulus Fibrosus) confines it. This entire
structure is held in its position between two vertebrae by tenacious
ligaments which themselves are attached to the bony vertebrae.
The ligaments virtually encircle the disc. They are particularly
dense in two areas running vertically in front (anterior) and in
back (posterior) of the disc area. These are called the
Anterior and Posterior Longitudinal Ligaments. They
play an important role in the pathological process of "herniated
discs", as well as in the long-term recovery from either conservative
or surgical treatments. Despite apparently successful treatment
(surgical or non-surgical) there is an element of risk for a
recurrence of the condition. The ligament (most particularly the
posterior longitudinal ligament) plays a vital role in this
The process of "aging" (when used in relationship to the disc and
the various joints of the spinal column) begins fairly early. The
rate at which it progresses depends on a number of factors, some
of which can be influenced by "life style" and habits. Others are
less amenable to an individual's control. Genetics or inherited
factors (with the exception of certain very rare diseases) probably
do not play any significant factor for the average patient. Humans,
by virtue of their bipedal (walking on two lower extremities) nature,
subject their spines to forces on a daily, relentless basis that
combine to accelerate a natural aging process. It is important to
recognize that this affects all of the joints of the spine as well
as the discs. The lower two lumbar levels (fourth and fifth lumbar,
L4-5; fifth lumbar and first sacral, L-5, S-1) assume a
disproportionate weight-bearing burden by virtue of their location
in the mechanism and function of the spine. This "daily" trauma is,
to a large extent, unavoidable. Other uncontrollable factors that
further accelerate this process include congenital abnormalities
of the spine (defects in the bone and/or muscular parts of the spine
that we are born with) or developmental defects of these structures
(those diseases which develop after birth such as progressive
abnormal curvatures called "Scoliosis").
For each person there are many more factors affecting the "aging" or
progressive "degenerative" process, that we can control, which are
influenced by daily activities and life styles. Obesity and
"over-weight" conditions add an unnecessary weight-bearing
requirement. Heavy lifting and repetitive bending (particularly
when standing up and leaning over at the waist to lift something)
are two factors that are frequent contributors in all societies
that require or encourage heavy work. Athletes or individuals who
pursue certain sports activities add another dimension of
accelerated disc and joint deterioration because of the added
repetitive trauma to these structures. Whether it is in a weight
lifter or jogger, football player or tennis enthusiast, each pursuit
exacts some price with respect to the spine and discs. None of this
should be misconstrued by the reader as suggesting that these
activities are either dangerous or undesirable. Good physical
conditioning helps to assure general wellness and is very desirable
from the point of view of slowing the progressive degenerative
processes that the spine is inevitably subject to. It is merely a
question of degree. We all must recognize that we pay a price for
some of the things that we do. The spine and its components are
among those parts of the body where added "wear-and-tear" frequently
results in an accelerated degenerative condition that ultimately
may cause that part to fail to continue to function adequately.
That the disc itself is subject to progressive degenerative changes,
with or without the influence of the "accelerating" factors, is
undeniable. Some joints in extremities can be successfully replaced
(knees, hips, and finger) although there is a limit as to how long
replacement joint materials will last. Recent research has resulted
in several devices for "lumbar disc replacement", several of which
have been approved by the FDA for human implantation. This is a
highly controversial area which is discussed in more detail in Part
2 of this Patient Information Series.
The related spinal joints (called Lumbar Facet Joints) are
points of motion which, in time, produces excessive "wear-and-tear".
When spinal joints are involved in this "wear-and-tear" process,
they react in a characteristic method to "protect" themselves. The
joint fluid ("Synovial Fluid") and joint surface lining (called
"Synovium") react in a characteristic fashion where the
lubricating fluid disappears and the lining becomes thicker, more
abundant ("Hypertrophic") and far less efficient. The Facet
Joints concurrently react to produce more bone in an attempt to halt
the wearing away. This new bone results in a progressively larger
("Hypertrophic") joint which encroaches on the spinal canal
(where spinal nerves exist) making the canal narrower ("Spinal
Stenosis"). This process involving the various components of
these joints is called "Degenerative Arthritis" or
"Osteoarthritis". Another characteristic aspect of this
"new bone" formation is the formation of "Bone Spurs" (also
called "Osteophytes.") The process of degenerative arthritis
is usually a very slow one. It is, to a degree, inevitable in
everyone. Some people, for many of the reasons outlined previously,
encounter it earlier and to a greater degree than others do. Despite
a well-advanced case, some people are not significantly affected
either by pain or neurological injury, whereas others can be
incapacitated. Unfortunately, there are no medications or treatments
that can reverse this "degenerative" process. Anti-inflammatory
drugs are usually helpful in reducing an acute flare-up of joint
Occasionally this process of progressive abnormal bone formation
results in very substantial Spinal Canal Stenosis (narrowing).
This narrowing is consequent to the overgrowth of the Facet
Joints as well as the Ligamentum Flavum ("Yellow
Ligament"). This special ligament lies beneath each Lamina
connecting one lamina to each other as part of the normal
stabilizing mechanism of the spine. The Ligamentum Flavum is
subject to stresses just as the Facet Joints are and, as a result,
it participates in this counter-productive degenerative process
which ultimately culminates in a pathologically thickened
(hypertrophic) and partially calcified Ligament. Once the Ligamentum
Flavum and Lumbar Facet joints have become sufficiently overgrown
to seriously compromise the diameter of the spinal canal and
Neural Foramina, substantial pressure is exerted upon the
Spinal Nerve Roots. This may result in severe pain in the
buttock and leg(s) when trying to walk some distance, a condition
known as "Cauda Equina Claudication." When the pain becomes
a major factor impairing the quality of life, then treatment
becomes necessary. In our neurosurgical practice, we frequently
see patients who have severe Spinal and Foramenal Stenosis.
It is this narrowing that squeezes the nerve roots in the spinal
canal and results in severe pain when trying to walk. There is
another (and probably more common) cause of "claudication" which
results from marked impairment of the blood supply to the lower
extremities, another manifestation of "Atherosclerosis"
("Hardening of the Arteries") The differentiation between
these two conditions is usually apparent using simple methods
during a physical and neurological examination. Occasionally a
more detailed investigation is required. Patients suffering from
claudication, may have some degree of isolated muscle weakness
and/or sensory loss. Once the claudication is severe, surgical
treatment becomes an important consideration.
A "Herniated Disc" (also called slipped, ruptured, misplaced,
displaced, dislocated) is a pathological situation. Although most
patients recover quite well without surgery, it is a sufficiently
common problem that frequently recurs multiple times in those
affected by it. One of the most frequent causes of the "herniated
disc" is a lifting or bending injury. Too much pressure is exerted
on the central portion (nucleus pulposus) of the disc. This results
in pressure against the confining capsule (Annulus Fibrosus) and
Posterior Longitudinal Ligament which are then stretched and
injured. The dislocated portion of the disc may push into the bony
spinal canal to press the nerve roots against the bone of the spinal
canal resulting in injury to the nerve root. A damaged nerve root
responds in a characteristic response, called "edema"
("swelling".) Unfortunately it swells against a hard bone surface
the spinal canal producing additional pressure on the nerve root and its blood supply, which results
in more injury to the nerve root and progressively more swelling.
In order to recover from this problem, two events must occur. The
pressure must come off the nerve root and the swelling must reverse.
These events can be promoted in a number of ways. The easiest
method of management is the most effective in accommodating both
of these requirements. It is straightforward and readily available
to all. It is BED REST.
BED REST accomplishes two things. By lying down, the pressure on the
disc, that ordinarily occurs when humans are upright, is diminished.
The inherent elastic strength of the Annulus Fibrosus and Posterior
Longitudinal Ligament will assist in the forcing the Herniated
Nucleus Pulposus to recede into the disc space, thus, reversing the
pressure on the nerve root(s) which then allows the nerve root
swelling to subside. The pain that accompanies this problem also
will improve significantly, particularly the portion that is deep
in the buttock and/or leg and foot.
Back pain is a frequent symptom that brings the patient to the
physician and may be a symptom of some other medical conditions
completely unrelated to actual spine problems. Your physician
will review the history of the problem and conduct a physical
examination that will include an evaluation of the spinal column
and nerve roots. The experience of a painful, stiff back is familiar
to most of us. The "stiffness" is usually the result of spasm or
tightness of the powerful muscles
("Paraspinal/Paravertebral Muscles") that lie along both
sides of the back of the Spinal Column. The spasm is the body's way
to attempt to immobilize the damaged joints. When the muscles
contract (tighten), they reduce the amount of movement that the
joints would ordinarily have. However, muscle spasm itself may
be quite painful. Some patients describe the tightness of the
muscle as "knots." Local application of heat (heating pad, moist
or dry "packs") or ice frequently offers significant relief for
the muscle spasm in conjunction with lying down. Careful attention
not to injure skin with the ice or heat is important. Massage
(with or without liniment, balms, salves or oils) also may offer
welcome relief from the pain of muscle spasm. In many cases of
"back pain," the problem is only with the muscle (such as a muscle
strain), and these measures often provide satisfactory relief.
However, any persistent or recurring, severe back, hip or leg pain
deserves a thorough evaluation by your physician. Medications are
frequently used to help relieve some of the pain of these problems.
Mild pain relievers are often necessary. Muscle relaxing and
anti-inflammatory medications are also commonly utilized. However,
some caution is needed. It should be remembered that pain is one
way that the body has to alert you that something is wrong. If you
take medication to relieve pain and continue to pursue the
activities that are producing damage, then you are probably doing
a serious disservice to yourself.
"Steroids" are very powerful "anti-inflammatory"
medications. Steroids are routinely used to limit and/or reverse
the "edema" (swelling) that occurs when the Brain, Spinal Cord or
Nerve Roots are damaged.
An increasingly popular treatment method is the injection of
steroids (with or without an anesthetic agent) into the spinal canal
in an attempt to reduce the swelling of damaged nerve roots. This
procedure, called "Epidural Steroid Injection" or "ESI"
involves introducing a needle or catheter inside an already
compromised spinal canal to deliver the steroids that are injected
"suspended" in a liquid rather than dissolved in "solution". There
are several issues surrounding this controversial "treatment". The
placement of the ESI catheter could result in more damage to the
nerve roots, adverse reactions to the injected medications and
hemorrhage from the many small blood vessels in the spinal canal.
When the "fluid" portion of the injected material is absorbed, the
"Epidural Steroid suspension" or ("carrier") substance remains
behind as a "sludge" that causes further scarring within the spinal
canal. We have had very many occasions to operate on patients who
have had Epidural Steroid Injections and have routinely found the
residual "sludge" material in the Epidural Space stuck to the
Dura Mater and/or calcified within the Ligamentum Flavum. Steroids
cannot improve upon an "extruded" or "herniated" disc; does
interfere with the normal healing process of the damaged Posterior
longitudinal Ligament; cannot positively affect any element that
is causing Spinal and/or Foramenal Stenosis such as Degenerative
Arthritic Lumbar Facets, Synovial Cysts and/or Ligamentum Flavum
Nevertheless, steroids can help to relieve the pain,
tingling/numbness and weakness that may result from nerve root
swelling occurring in conjunction with an acutely injured nerve
root in cases of a Herniated Disc or Spinal (and/or Foramenal)
Stenosis. In our experience, it is more appropriate to attempt a
short course of oral steroids (taken in pill form by mouth in those
patients where it may be of benefit) rather than risk injections
into the spinal canal. Oral steroids (usually in the form of
"methylprednisolone") are usually sufficient to achieve the desired
result. In some patients, more potent steroids ("dexamethasone")
may be required.
The old treatment concept of "Lumbar Traction" is being
re-established using more modern technology including "computerized
devices". All of the "traction" methods attempt to decrease the
pressure inside the disc space by using some type of pelvic
"pulling" force in an attempt to "separate" the disc spaces (a
matter of a few millimeters). This creates a "vacuum" allowing the
"herniated" disc fragment(s) to recede into the disc space. Simple
devices include a corset attached to a rope, pulley and weight
system that the patient can use, in bed, at home. Another is a
"gymnastic" set-up where the patient "hangs" in an inverted position
and uses his own body weight as the "traction" force. Other more
sophisticated computerized traction devices can be found in some
chiropractic, orthopedic and neurosurgical offices. Clearly there
is some merit to these treatments although it is important to
carefully select those patients for whom this would be appropriate.
The limiting factors for recovery, and also those which may result
in incomplete recovery or recurrence of the herniated disc, are the
tissues that are intimately related to the disc that were damaged as
well. Those tissues are the disc capsule (Annulus Fibrosus) and
the confining Posterior Longitudinal Ligaments. Once these are
stretched ahead of the herniated disc, they are very slow to recover.
Even when the disc recovers its more normal position and the capsule
and ligaments are no longer under the forces of stretch, they are
still in a weakened condition. Some patients are fortunate in that
the ligament heals well after the first episode and never bothers
them again. In others, these structures never regain adequate
strength resulting in multiple recurring episodes over varying
periods of time from months to years. Alternatively the initial
episode may be sufficiently traumatic that conservative therapy, no
matter how carefully it is carried out, may fail and other more
aggressive treatment techniques may become necessary. No one can
accurately predict, ahead of time, what course is determined for a
particular patient with a herniated disc (except in a very special
set of circumstances which invariably are accompanied by serious
or advancing neurological deficit). Only after an initial trial of
conservative therapy can one begin to identify what further
treatment course should be recommended. As a general rule, strict
and complete bed rest on a well-designed mattress (not too hard
and not too soft) for a minimum of five (5) days is indicated in
most patients. The majority will improve. In these cases complete
bed rest for an additional nine (9) to fourteen (14) days will be
required to allow the capsule and ligaments to begin to heal.
In cases of a large disc herniation, the capsule and ligament will
not heal for months (if ever). During this time the patient should
exercise care, caution and good common sense with respect to their
activities. The problem is with the Annulus Fibrosus capsule and
Posterior Longitudinal Ligament. Early return to an exercise
regimen that produces pressure on the disc may very well result
in an early recurrence. Common sense alone should indicate which
activities and body positions are likely to be injurious.
Activities that produce pain should be avoided. Pain is the body's
way to alert us that something is wrong tissues may
be injured. Exercise programs obviously have no place in the early
management of this problem.
There are some patients who, despite a trial of complete bed rest,
do not improve or suffer a recurrence early after getting up from
bed rest. In these situations, both the ligament and disc capsule
are so badly damaged that they cannot hold the disc in place. This
is called an "Extruded Disc" and refers to a situation where the
disc material has torn a hole in the confining disc capsule and
ligament allowing part of the disc to escape into the spinal canal.
The capsule and ligament are made of elastic tissue resulting in
the closing over of the hole through which the disc "extrudes".
The disc cannot be repositioned by any method, and these patients
become surgical candidates. Spinal manipulation is inappropriate
and potentially very likely to produce further neurological damage
in the case of an extruded disc. No reasonable force could push
this disc back into place.
Back pain is often the major symptom of muscle strain, spinal joint
problems or a herniated disc. Hip and leg pains are usually the
result of pressure injury to the nerve root. The experience of
tingling, numbness and/or weakness of leg (or foot) muscle are the
result of more serious damage to the nerve roots. The medical
term for a nerve root injury is Radiculopathy. The presence
of symptoms of radiculopathy requires early medical evaluation and
treatment. For most patients, proper treatment under medical
supervision will alleviate the problem early and reduce the
likelihood for and the extent of a chronic, more severe disorder.
Your physician, after an initial examination, may order plain x-rays
of the lumbar spine. These x-rays allow for the evaluation of the
bone structure but cannot identify whether or not a herniated disc
is present. There are some other examinations which can be
obtained; however, they are much more expensive and unnecessary for
Computerized Tomography (CT or CAT) scan is an x-ray
examination that permits us to evaluate both the bone of the
spinal column and (to some extent) the disc structures. Its
primary usefulness, for spine patients, is in evaluating bone
Magnetic Resonance Imaging (MRI) scan is a non-x-ray
technique that is often used as the first (or screening) neuroimaging
method in many patients. While it has some limited usefulness in
evaluating bone anatomy, it is an excellent technique for evaluating
the Spinal Cord (which is rarely involved by lumbar region disc
disease since the spinal cord "ends" near the L1 level), Nerve
Roots and also allows us to look at the anatomy of the disc.
Oftentimes this is the only neuroimaging method that we will need.
In rare instances it will demonstrate the presence of a tumor
(almost always benign) in the spinal canal. MRI scanning is very
useful in evaluating the Thoraco-lumbar junction of the spine.
The Thoracic area of the spine lies just above the Lumbar
region. The "junction" between these two regions is a frequent
location for advanced degenerative disease in older people.
There is one other investigative technique that is very important.
"Myelography" coupled with "Post-myelographic CT Scanning"
is regarded as the "gold standard" neuroimaging method for evaluating
spine problems. However, we reserve this for patients who are
operative candidates in whom MRI and/or CT scans have not fully
explained the anatomical condition. This is an "invasive procedure"
requiring the placement of a needle and a radiographic dye substance
into the spinal canal and is not to be considered as part of a
routine evaluation for spine patients nor is it required for all
patients who are to undergo spinal operative intervention. The
specific indications for this procedure are reviewed in PART 2 of
this Patient Information Series.
Other investigation methods such as Bone Scanning, Bone Density
testing and Positron Emission Tomography (PET) are generally
not required for patients with new onset of symptoms. In the event
that routine testing (such as reviewed in the preceding paragraphs
of this document) does demonstrate some additional problems then
these other tests may become appropriate.
The details of the follow-up care and treatment regimen for the
recovering patient, after an initial favorable response to
conservative therapy, are usually custom designed for that patient.
When to begin to use exercise and which types of exercise are
matters to be reviewed with the physician, as is the concern for
a properly nutritional diet. Diets based on food fads can be harmful
by virtue of not providing agents necessary for the recovery of
damaged tissues. A nutritionally well-balanced diet, with an
emphasis on "proteins" (the "building blocks" of tissue repair, is
necessary. Where obesity is an additional factor, a major effort at
weight reduction must be made, taking into account that "proper"
nutrition must be provided to the damaged tissues. In these cases a
firm recommendation is usually made to consult a nutritionist and/or
a physician who is well acquainted with weight control and weight
A final thought concerning this problem of a herniated disc
should be kept in mind. There are no "quick fixes" available. A
basic understanding of the underlying injury to tissues will help
guide the informed patient to seek their choice of treatment.
Whatever choice is made, one should remember that damaged tissues
take time to heal and, when in a weakened condition, are more likely
to be re-injured more severely. Despite all of this, most patients
recover satisfactorily. It is only a small minority of patients with
"back pain" who ever really require surgical intervention.
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This page last edited on 2/20