Herniated Disc

Herniated Disc Overview

Made up of 24 bones called vertebrae, the adult spine is also home to 23 discs between each vertebra that act as shock absorbers when the spine moves and bends. Inside each disc is a soft, jelly-like center called the nucleus pulposus, while on the outside, a tough layer called the annulus fibrosus protects the spongy center.

When the soft center of a disc pushes through a tear in the outer layer, a herniated disc occurs. If the protruding disc fragment then puts pressure on the spinal cord (cervical or thoracic herniation), it can cause back pain and spinal cord dysfunction. If it’s in the lumbar spine, it can cause nerve root compression and sciatica. The disc fragment also releases chemical irritants that can lead to inflammation.

Also known as a slipped disc or ruptured disc, a herniated disc can happen in any part of the spine. Discs can tear due to injury, degeneration due to aging, or a combination of the two. A herniated disc is most common in the lower back or lumbar spine, followed by the neck or cervical spine. Herniated discs are least common in the middle part of your back, known as the thoracic spine.

The size of the herniated disc does not necessarily correlate to the intensity of symptoms. For example, a large herniation may not cause much pain if a nerve root is unaffected. Meanwhile, a small disc herniation can cause significant discomfort if a nerve root is severely compressed or inflamed.

Herniated Disc Symptoms

The symptoms of a herniated disc vary. If the disc isn’t pressing on a nerve, symptoms might be limited to a minor aches or no symptoms at all. If the disc is pressing on a nerve, there’s often pain, numbness, or weakness in the area of the body where the nerve travels.

The symptoms you might notice if you or someone you know has a herniated disc in the lower back or lumbar spine may include:

• Lower back pain: Pain at the site of the herniated disc happens due to the displaced disc fragment pressing on spinal nerves and causing pain.
• Sciatic nerve pain: A sharp, shooting pain that radiates from your buttocks down the leg that can occur due to pressure on the spinal nerve.
• Weakness in the leg or foot: This results from the herniated disc pressing on a nerve that travels down to one leg or foot.
• Bowel and bladder dysfunction: Though rare, compression of the spinal nerve roots can cause bowel and bladder issues and calls for prompt medical attention.

Symptoms of a herniated disc in the neck or cervical spine can include:

• Dull or sharp pain in the neck or between the shoulder blades: Herniated discs in the neck can extend to the shoulder and arm, and the resulting pain can feel sharp or burning.
• Neck pain that increases with movement: Movements involving the extension or rotation of the neck can aggravate nerve compression because they change the position of the vertebrae and discs, potentially increasing pressure on the area.
• Neck pain that radiates down the arm to the hand: Nerve root irritation in the cervical spine can produce referred pain or pain felt in the areas served by the affected nerves, such as the shoulders, arms, or hands.
• Numbness or tingling in a shoulder or arm: A herniated disc in this part of the spine can induce numbness and tingling that radiates to a nearby limb.

Symptoms of a herniated thoracic disc may include:

• Difficulty walking: The compression of the spinal cord in the thoracic spine can lead to motor and sensory deficits, manifesting as leg weakness, balance issues, and pain, impairing walking ability.
• Pain in the mid back, which may wrap around the chest: The pain from a compressed spinal nerve in the thoracic spine may be more severe, as the spinal canal in this part of the spine is smaller than the other two regions.
• Progressive weakness and numbness in lower extremities: A herniated disc in the thoracic spine can cause progressive weakness and numbness due to the compression of the spinal cord and the nerves that branch off from it.  
• Bowel and bladder dysfunction: Compression of the spinal cord or nerve roots can disrupt the nerves that control bladder and bowel functions.

Discomfort from a herniated disk usually worsens when you’re active and lessens when you’re resting. Certain positions or activities, like twisting your spine, bending forward at your waist, sitting for a prolonged time, or lifting too-heavy objects, can cause additional inflammation or compression of the affected nerve.

To help alleviate your symptoms, the following positions can help:

• Sitting in a reclined position
• Lying on your side or back with a pillow between or under your knees
• Lying flat on your back with your hips and knees at 90 degrees

For some people, continuing to engage in non-strenuous activity or taking short walks can reduce the likelihood of pain.

S

Your doctor may use some or all of the following:

• Medical review and neurological exam: First, your healthcare provider will ask about your symptoms, overall health, and family history. Next, they’ll test your reflexes, muscle strength, walking ability, and response to sensory stimuli.
• Physical exam: A simple straight leg raise test can often indicate a herniated disc. While on your back, your provider will help you raise your symptomatic leg without bending it. If this triggers pain in the raised leg or increases pain, irritation or sciatic nerve compression is inferred.
  • Crossed straight leg test. Also called the “well leg” raise test, this is a variation of the straight leg raise test that involves raising the leg without painful symptoms. If raising this leg creates pain in the non-raised leg, it can indicate irritation or compression of a sciatic nerve root. 
  • Lumbar spine exam. This involves a range of motion testing while bending backward, forward, and in a spinal rotation. Your standing and sitting postures are also evaluated.
• Magnetic Resonance Imaging (MRI): Imaging studies are crucial in visualizing the spinal cord or spinal nerves and identifying abnormalities. An MRI provides images that can locate the position of the herniated disc and determine which nerves are affected. An MRI can also help rule out non-spine-related causes of pain.
• Computed Tomography (CT) scan: A CT scan takes multiple X-rays from different angles and combines them to create images of your spine and its surrounding structures. However, CT scans aren’t relied on as heavily in diagnosis since disc herniation isn’t visible on an X-ray.
• Electrodiagnostic tests: Although less common, your doctor may enlist these tests to determine if any nerves in your spine are damaged or compressed. Electromyography (EMG) involves a small needle electrode inserted into the muscle to record the electrical activity of your muscles at rest and while they contract. A Nerve Conduction Study (NCS) evaluates a nerve’s ability to send signals along the nerve or to the muscles.

Using simple tests, combined with diagnostic tools when needed, leads to the proper diagnosis and helps your healthcare team create a tailored treatment plan for you.

This illustration depicts a herniated disc in the cervical spine putting pressure on a spinal nerve root. It also shows the placement of a tube used during minimally invasive spine surgery.

Herniated Disc Treatments

Herniated disc treatment typically involves a combination of self-care, medications, decreased activity, and physical therapy. If these more conservative treatments fail, your doctor might prescribe epidural blocks. In some cases, you may need spine surgery.

Your specific treatment plan will depend on your symptoms’ severity and overall health. That said, most treatments involve lifestyle changes and incorporating exercise-based therapies to maximize healing and minimize the odds of reoccurrence.

Non-Surgical Treatment

The good news is that most herniated discs don’t require surgery. After diagnosis, doctors will often prescribe a conservative treatment plan of rest and a reduced activity level, anti-inflammatory medication, and physical therapy.

One to two days of bed rest can help relieve back and leg pain. However, it’s not recommended to rest longer than that—prolonged bed rest can lead to muscle stiffness and weakness.

As activity is gradually resumed, it’s best to take the following precautions:

• Be mindful of resting throughout the day, but avoid sitting for long periods
• Keep physical activity slow and steady, especially when bending or lifting
• Avoid movements that may cause further pain

In addition to initial rest and caution with movements, the following therapies are often recommended:

• Physical therapy: Generally focused on movements and stabilization to reduce nerve compression, physical therapy can include exercises to increase flexibility and strengthen the muscles supporting the spine, ultrasound techniques, and electrical muscle stimulation. Pain medication and muscle relaxants can be combined with physical therapy to minimize discomfort.
• Massage therapy: Deep tissue or neuromuscular massage therapy can help relieve muscle spasms, relax tight muscles, and promote healing. A bonus is the pain-relieving endorphins released during and after massage.
• Spinal manipulation: Chiropractic adjustments or osteopathic manipulations can relieve pain and improve function in the back or leg in the event of sciatica.  
• Hot and cold therapy: While heat relaxes tight muscles, increases blood flow, and reduces spasms, applying ice or cold packs will reduce inflammation and relieve pain.
• Acupuncture: Inserting hair-thin needles into specific areas of the skin stimulates the nerves affected by a herniated disc, reducing symptoms.
• Injection treatments: If rest, pain relievers, and physical therapy aren’t providing relief, your doctor might suggest an injectable steroid like cortisone. Known as an epidural injection, the steroid injected into the space around your spinal nerve can help ease pain and help bring down swelling, which leads to greater mobility.

If your herniated disc symptoms persist for more than four weeks, your doctor may refer you to a spine surgeon.

The two most common surgical procedures for a herniated disc include a discectomy and a microdiscectomy. While both procedures remove the herniated portion of the disc to relieve pressure on the nerve, they differ in their procedural protocol and recovery time:

• Discectomy: In a traditional discectomy, your neurosurgeon will make a larger incision in the back or neck to access the spine and remove part or all of the herniated disc (cervical spine) part of the disc (lumbar and thoracic). Using direct visualization of your spinal structures, your neurosurgeon will need to retract your muscles and tissues more extensively, and recovery may take longer due to the more extensive tissue manipulation.
• Minimally invasive discectomy (microdiscectomy): A minimally invasive discectomy, or microdiscectomy, is done through a small incision at the site of the disc herniation, frequently through specialized dilation tubes and a microscope. It is usually an outpatient surgery. In this procedure, your neurosurgeon will remove the protruding fragment of the disc that’s compressing the spinal cord or spinal nerves. This minimally invasive approach leads to less tissue damage, less blood loss, and fewer cases of postoperative infection at the surgical site.

At Barrow Neurological Institute, our spinal surgeons are leaders in minimally invasive techniques for disc herniation and employ highly specialized instruments to operate through smaller incisions. Benefits of minimally invasive surgery at Barrow include:

• A shorter hospital stay
• Less postoperative pain
• Reduced blood loss
• Faster recovery

It’s important to discuss the advantages of surgical and non-surgical treatments with your healthcare provider, as every surgical procedure carries risks. Known risks for herniated disc surgical treatment include bleeding, infection, nerve injury, or a tear in the sac covering the nerves (known as a dural tear).