Welcome to Hicksville Physical Therapy’s patient resource about Lumbar Disc Herniation.
Herniated discs can often be called “slipped discs,” but this name is a bit of a misnomer. The disc doesn’t slip out of place, but instead, its center squeezes out of its regular space (a process called “herniation”). Most patients with lumbar disc herniation are 30 to 40 years old.
This guide will teach you about:
What parts of the spine are involved?
24 vertebrae (spinal bones) make up the human spine. These vertebrae are stacked atop each other to make up the spinal column, which gives the body its form and provides upright support. The lumbar spine is located in the lower back.
The lower five vertebrae (often called L1 to L5 by physicians) are considered the lumbar spine. These vertebrae are responsible for the lower back’s inward curve. L5, the lowest vertebrae in the lumbar spine, connects to the sacrum, a triangle-shaped bone at the spine’s base that fits in the middle of the two pelvic bones. Some people may have an extra lumbar vertebra (totaling six instead of five), but this additional vertebra usually does no harm.
Intervertebral discs separate the vertebrae and are made from connective tissue, which holds the body’s living cells together. Most connective tissue is made from collagen fibers, which allow the disc to handle pressure and tension.
A disc is made up of two parts: the nucleus and the annulus. The nucleus is spongy and allows the disc to absorb shock. The annulus holds the nucleus in place and is made of strong ligament rings. Ligaments are connective tissues attaching bones to one another.
Healthy discs cushion the spine like shock absorbers, protecting the spine from gravity’s pull. These discs also protect the spine during taxing activities like lifting, jumping, and running.
Why do I have this problem?
Herniation happens when the nucleus is pushed out of its regular space in the middle of the disc. The nucleus pushes against the annulus, which makes the disc bulge outward. In some cases, the nucleus will herniate completely through the annulus and leave the disc altogether.
The body can typically handle the pressure when the nucleus pushes against the annulus. But as the annulus gets older, it can tear and crack. These weak points are repaired with scar tissue in a process called degeneration. With time, the annulus gets weather, and the nucleus may herniate (squeeze) through the impaired annulus. At first, the annulus bulges outward because of the pressure, but with time, the nucleus may move completely out of the disc.
Vigorous and repetitive lifting, twisting, and bending can increase pressure on the nucleus, impacting its ability to absorb shock. If the pressure is too great, the annulus can become injured, and herniation may occur.
An acute (sudden) injury can also lead to lumbar disc herniation. Lifting heavy objects by twisting and bending the trunk forward can lead to a herniated disc. Disc herniation may also result from a heavy impact on the spine, like falling from a significant height and landing in a seated position.
Herniation can be painful in multiple ways. Lumbar disc herniation can cause mechanical pain, which comes from sections of the spine that move during activity, like ligaments and discs. Pain from inflammation can result when the nucleus passes through the annulus. Normally, the nucleus doesn’t come into contact with blood, but a tear in the annulus can cause the nucleus to meet the blood. When the blood supply and the nucleus meet, the chemicals inside the nucleus are impacted, which can cause pain and inflammation. A herniated disc can also increase pressure on a spinal nerve, which can cause neurogenic pain, which is pain that travels along the nerve.
Degenerative changes in the spine can lead to lumbar disc herniation. These changes happen slowly over time and eventually lead to a herniated disc. In the beginning, patients may only experience dull pain in the lower back, and this pain will often come and go over a few years. Doctors believe this waning pain is a result of small tears in the annulus. Larger cracks, however, may cause pain into the buttocks and lower limbs.
When a herniated disc travels all the way through the annulus, Symptoms usually start immediately, beginning with a sharp pain in one hip that travels down some or all of the leg. Typically, patients will only feel leg pain at this point and will no longer experience back pain. When the nucleus pushes completely through the annulus, the painful tension on the annulus releases, relieving back pain.
Herniated discs can produce inflammation when the nucleus meets the blood, as discussed previously. This inflammation can cause throbbing pain in the lower back and can affect the hips and buttocks.
Herniated discs may also push against spinal nerves, causing nerve compression symptoms. Nerve pain subscribes to verified patterns in the lower limbs. This pain can be experienced in the side of the thigh, calf, foot, and toes.
Nerve pressure may also cause feelings of pins, needles, and numbness where the nerve travels through the lower limbs. In these cases, reflexes will slow down. The muscles that the nerve controls will weaken, and sensations in the impacted area are impaired.
In rare instances, patients may experience changes in bladder and bowel function. A large disc herniation that pushes directly into the spinal canal can increase pressure on the nerves leading to the bladder and bowels. This pressure can result in lower back pain, pain in the back of the legs, and tingling or numbness between the legs (located in the area where your body would touch a saddle or a bike seat). Sometimes, this nerve pressure can make a patient lose control of their bladder or bowels. This condition is an emergency and should be treated immediately. If the pressure is left untreated, the bowels and bladder may be permanently paralyzed, a condition known as cauda equina syndrome. Doctors will often perform surgery immediately to remove pressure from the impacted nerves.
In rare instances, patients may experience changes in bladder and bowel function. A large disc herniation that pushes directly into the spinal canal can increase pressure on the nerves leading to the bladder and bowels. This pressure can result in lower back pain, pain in the back of the legs, and tingling or numbness between the legs (located in the area where your body would touch a saddle or a bike seat). Sometimes, this nerve pressure can make a patient lose control of their bladder or bowels. This condition is an emergency and should be treated immediately. If the pressure is left untreated, the bowels and bladder may be permanently paralyzed, a condition known as cauda equina syndrome. Doctors will often perform surgery immediately to remove pressure from the impacted nerves.
Non-surgical Rehabilitation
Unless you are lumbar disc herniation is rapidly worsening or is causing significant issues in your daily life, you will usually begin with non-surgical treatment options. Most patients with lumbar disc herniation improve without surgery. So, most patients should try non-surgical treatment for at least six weeks before thinking about surgery.
In the beginning, your physical therapist from Hicksville Physical Therapy will likely want to immobilize your lower back. Holding the back still for a while can reduce pain and inflammation. You may be on bed rest for a period of time, as lying on your back can relieve the pressure typically placed on sore nerves and discs. However, our team typically does not advise strict bed rest, instead encouraging patients to continue normal activities to determine how much pain is too much. If bed rest is prescribed (which is rare), it will typically be for a maximum of two days.
Some patients with lumbar disc herniation benefit from a back support belt, which can decrease the pressure inside the impacted disc. We encourage patients to gradually use the support belt less frequently over a two-to-four-day period. Otherwise, the trunk muscles will start to depend on the belt and will begin weakening and atrophying (weakening).
Our physical therapy treatments aim to help you reduce pain, improve movement in the back, and encourage healthy posture. The first goal will be to control your symptoms. Your physical therapist will work with you to find movements and positions that reduce your pain. Throughout the first few sessions, you may use treatments of heat, cold, ultrasound, or electrical stimulation. Lumbar traction is also common in early appointments, helping to ease lumbar disc herniation symptoms. Additionally, your physical therapist may turn to more hands-on treatments like massage therapy or spinal decompression. These treatment methods are used to lower pain and inflammation levels, allowing you to get back to daily life quickly.
Your physical therapist will also demonstrate how to keep your spine protected during your daily activities. You’ll be taught proper posture and how it can impact the future health of your spine. You will also learn about body mechanics, which are the ways that the body moves and works during various activities. We teach patients about body mechanics to help them protect and support the lower back throughout the day. You’ll learn proper positions and movements to use while carrying, lifting, walking, standing, and performing duties applicable to your work.
Next, you will move to a program of strengthening exercises that target your abdominal and lower back muscles. As you strengthen these core muscles, you’ll begin to move easier and will have a reduced chance of future issues and pain. Aerobic exercises like swimming and walking are ideal for reducing pain and increasing endurance.
Our team will work with your employer and your doctor to help you resume your job duties as quickly as safely possible. You may be required to ease into your work, but as soon as you can, you’ll go back to your normal job activities. Our therapist can perform a work assessment to ensure you will be safe and healthy performing your duties. You may be recommended changes to your routine that can allow you to work safely and reduce the chance of reinjury.
One of the main goals of your physical therapy is to learn how to handle your symptoms and prevent future issues. You’ll be given a home program of exercises supporting endurance, posture, flexibility, and strength in the lower back and the abdomen. Your physical therapist will also provide strategies to use in case of flare-ups.
When patients are seeing no results throughout therapy, or if the issue becomes worse, surgery may be necessary.
Post-surgical Rehabilitation
Rehabilitation following surgery is more complicated than standard rehabilitation. While some patients don’t have to end or an extended hospital stay after surgery, others may find themselves in the hospital for a few days.
During your recovery, carefully follow any instructions concerning the use of back braces or support belts. You should also avoid overdoing any activity in the first few weeks following your surgery.
Recovery time is very from patient to patient, but in general, you can expect to see a physical therapist for one to three months, depending on the specific surgery you’ve had. In the beginning, your physical therapists will likely use treatments like massage, ultrasound, electrical stimulation, or heat and ice to reduce pain and muscle spasms. We’ll reassure you and show you how to deal with fear and hesitancy about pain. Then, you’ll learn how to safely move without straining your back as it heals. Exercises will build endurance, strength, and flexibility.
When you’ve been in recovery for a while, you will no longer attend regular visits to Hicksville Physical Therapy. We will still be a resource for you, but you will take charge of your own exercises in a continuing home program.
Computed tomography (a CT scan) may be ordered. A CT scan is a detailed X-ray revealing slices of the body’s tissue. CT scans can show whether lumbar disc herniation is putting extensive pressure on a spinal nerve.
In some cases, doctors combine CT scans with myelography. A special dye is injected to fill the space surrounding the spinal canal, also known as the subarachnoid space. During the CT scan, the dye emphasizes the spinal cord and nerves, which can lead to a more accurate diagnosis of a herniated disc.
If your doctor needs more information, they may turn to magnetic resonance imaging (MRI). MRI machines use magnetic waves (not X-rays) to display the body’s soft tissues, providing a clear image of the discs and any herniations that may be present. Like in a CT scan, an MRI will show images of the “slices” in the area your doctor needs to see. MRIs do not require needles or special dyes.
Sometimes, doctors will use a specialized X-ray called discography. Dye is injected into one or several discs, then the dye can be seen on an X-ray to give more information about the discs’ health. This test could be used when considering surgery and to determine which disc is the cause of the pain.
Doctors could also order electrical tests to more accurately determine which spinal nerve is being impacted. Several different tests may be used to check nerve function, including an electromyography (EMG) test. This test measures the length of time it takes for a muscle to work after a nerve provides a signal to move. If a herniated disc is putting pressure on a nerve, it will take longer. Another possible test is the somatosensory evoked potential (SSEP) test, which measures nerve sensations. Sensory impulses make their way up the nerve to tell the body about touch, temperature, pain, and other sensations. The nerve function is recorded by an electrode placed over the relevant area of skin. These tests are usually performed before lumbar disc herniation surgery.
Some patients with persistent systems will be given epidural steroid injections (ESI). Steroids can be effective at reducing inflammation. During an ESI, medication is injected into the area surrounding the lumbar spinal nerves where they move away from the spinal cord, also known as the epidural space. While some doctors will only inject a steroid, most will combine the steroid with a long-lasting numbing medicine. In general, an ESI is only provided when other treatments bring no results. ESIs do not always relieve pain, and if they do, the relief is only temporary in most cases.
If your symptoms are mild and don’t appear to be getting worse, you will typically not require surgery. However, if pressure begins to build on the spinal nerve, surgery may be necessary (immediately, in some cases). To determine whether surgery is needed, doctors will watch for weakening leg muscles, pain that will not reduce, and issues with the bladder or bowels.
Types of lumbar disc herniation surgery includes:
Laminotomy and Discectomy
The lamina forms a “roof” over top of the spinal canal. During this procedure, a small section of the lamina is removed (laminotomy), allowing the surgeon to remove the impacted disc (discectomy). This procedure is common when the herniated disc is placing pressure on a nerve and pushing pain down one leg.
Microdiscectomy
Microdiscectomy is quickly becoming the most common surgery for herniated discs. This procedure is common when a herniated disc is impacting a nerve root. The surgeon will carefully remove a section of the problem disc (discectomy). The surgery requires a surgical microscope, meaning the surgeon only has to make a small incision in the lower back. Microdiscectomy is considered a minimally invasive surgery and is believed to be less taxing for patients. Some believe that this surgery is also easier to perform, results in reduced scarring around the joints and nerves, and leads to quicker recovery.
Posterior Lumbar Fusion
Herniated discs cause mechanical pain, a type of pain caused by wear and tear in sections of the lumbar spine. Fusion surgery is often used to halt movement of the impacted area by combining two or more vertebrae into one bone, keeping the bones and joints in place and reducing mechanical pain.
During posterior lumbar fusion, the surgeon lays small grafts of bone on top of the impacted area on the back of the spinal column. Many surgeons also apply metal plates and screws to keep the vertebrae still, protecting the graft to bring quicker and more effective healing.
