As a disc degenerates and breaks down, the inner core, or nucleus pulposus, can leak out through the outer portion of the disc (annulus), and this condition is known as a disc herniation or a herniated disc. The weak spot in the annulus of the intervertebral disc is directly under the spinal nerve root, so a herniation in this area puts direct pressure on the nerve.
The nerve runs through the leg, and any type of pinched nerve in the lower spine can cause pain to radiate along the path of the nerve through the buttock and down the leg. This type of pain is also called sciatica or radiculopathy.
Lumbar Herniated Disc Symptoms
General symptoms typically include one or a combination of the following:
- Leg pain (sciatica), which may occur with or without lower back pain. Typically the leg pain is worse than the lower back pain.
- Numbness, weakness and/or tingling in the leg
- Lower back pain and/or pain in the buttock
- Loss of bladder or bowel control (very rare), which may be an indication of a serious medical condition called caudal equine syndrome.
Lumbar Disc Herniation Symptoms
- L4-L5 and L5-S1 Disc Herniation Symptoms
- The vast majority of disc herniations will occur toward the bottom of the spine at L4- L5 or L5- S1 levels. In addition to typical sciatica symptoms, nerve impingement at these levels can lead to:
- L5 nerve impingement (at the L4-L5 level) from a herniated disc can cause weakness in extending the big toe and potentially in the ankle (foot drop). Numbness and pain can be felt on top of the foot, and the pain may also radiate into the buttock.
- S1 nerve impingement (at the L5-S1 level) from a herniated disc may cause loss of the ankle reflex and/or weakness in ankle push off (patients cannot do toe rises). Numbness and pain can radiate down to the sole or outside of the foot.
Lumbar Herniated Disc – Non-operative Treatments
Most lumbar disc herniations will heal themselves gradually over time. In most cases, if a patient’s pain is going to get better it will start to do so within about six weeks.
While waiting to see if the symptoms will abate on their own, several non-surgical treatments can help alleviate the pain and facilitate long term healing. The most common herniated disc non-surgical treatments include:
Activity Modification. It is very important to avoid activity that increases pressure in the disc and irritation of the nerve especially forward bending, twisting at the waist, heavy lifting and prolonged periods of sitting. Generally speaking “if it hurts, don’t do it”.
Physical therapy. A proper therapeutic exercise program should include the elements of flexibility, progressive strengthening and cardiovascular conditioning. Flexibility exercises should focus primarily on the lower extremities and hip girdle. Strength training, particularly CORE strengthening for the abdominal and paraspinal muscle groups, is important for dynamic stabilization/support of the spine. McKenzie exercises based on directional preference are fundamental in the management of disc disorders. Cardiovascular training through walking, jogging, treadmill, elliptical trainers, biking and swimming is important for overall health, weight control, and decreasing pain associated with degenerative conditions.
McKenzie Therapy is a specific type of physical exercise which can be very helpful in managing lumbar herniated discs and back pain associated with disc problems. McKenzie therapy is based on the principal of directional preference. In most cases disc problems are better treated with exercises done in neutral or extension alignment of the lumbar spine while avoiding flexion based movements. By respecting each person’s directional preference, McKenzie Therapy can help reduce the pressure in the disc and relieve leg pain. This therapy is self administered after being instructed to the patient following an evaluation by a certified McKenzie therapist. To find a certified Mckenzie Therapist you can visit the McKenzieinstitiutenorthamerica.com.
Heat and/or ice therapy
Osteopathic/chiropractic manipulation (manual manipulation)
Non-steroidal anti-inflammatory drugs (NSAIDs)
Short term oral narcotic pain medication to improve comfort.
Nerve medications such as Neurontin and Lyrica to reduce neuropathic (nerve) pain and improve sleep
Oral steroids (e.g. prednisone or methyprednisolone)
An epidural steroid (cortisone) injection
It is reasonable to continue non-operative treatments for a period of three to six months as long as the symptoms continue to improve during that time period. If the pain and other symptoms fail to improve after six weeks, and if the pain is severe, it is reasonable to consider microdiscectomy surgery as an option.
Recurrent Disc Herniation
Unfortunately, approximately 10% of patients will experience another disc herniation at the same location. This recurrence is most likely to happen early in the postoperative period (within the first three months), although it can happen years later. Usually a recurrence can be handled with another microdiscectomy.
If it recurs multiple times, a lumbar fusion surgery to stop the motion at the disc level and remove all of the disc material may be considered.