Lumbar Herniated Disc (Herniated Disc in the Lower Back)
A herniated disc, commonly referred to as a lumbar herniation, occurs in the lumbar region of the spine, which consists of five vertebrae numbered from 1 to 5. The most common herniations occur between the fifth lumbar vertebra and the first sacral vertebra, known as L5-S1, and between the fourth and fifth lumbar vertebrae, known as L4-L5.
A herniated disc forms when the outer back portion of the intervertebral disc, which lies between the vertebral bodies and is similar in texture to rubber, tears or bulges backward. The disc facilitates movement between the vertebrae and acts as a cushion that absorbs the body's weight. The disc structure consists of an outer layer called the annulus fibrosus and an inner core called the nucleus pulposus. The outer layer is more rigid and resistant to trauma. The weakest area of the outer layer is located in the middle-posterior section, and most herniations occur due to tears in this region.
Assoc. Prof. Dr. İsmail Oltulu answers frequently asked questions about lumbar herniated discs.
What Are the Symptoms of a Lumbar Herniated Disc?
In a lumbar herniated disc, the protruding part of the disc can press against the spinal cord or nerve roots emerging from the spinal cord within the spinal canal, or it can cause irritation in these nerve roots due to inflammation it creates. While some patients may experience mild symptoms, others may suffer from unbearable pain. The common symptoms in patients include:
- Leg pain
- Lower back pain
- Numbness, tingling, or loss of sensation in the leg
- Muscle weakness in the legs, foot drop in advanced cases
- Loss of bladder or bowel control in severe cases
Symptoms can also vary depending on the location of the herniation. For example, a herniated disc pressing on the right nerve root at the L3-L4 level can cause pain between the groin and thigh on the right side, as well as weakness in the muscles attached to the right kneecap. Similarly, a herniation pressing on the left side at the L5-S1 level can cause pain radiating from the left hip to the ankle and even the toes, as well as numbness, loss of sensation, and in advanced cases, paralysis of the ankle muscles known as foot drop.
Are Non-Surgical Treatments Effective for Lumbar Herniated Discs?
In most cases of lumbar herniated discs, surgery is not necessary. However, there are situations where surgery is absolutely required. For cases outside of these situations, non-surgical treatments should be applied, and surgery should only be considered if symptoms persist despite these treatments. On average, the herniated disc in approximately 70% of patients will naturally resorb, meaning it shrinks and disappears on its own without any treatment.
There is a common misconception among people. This is a natural process, and external treatments such as laser therapy or other methods do not eliminate the herniation. Most herniated discs dissolve on their own through the body's natural repair mechanisms, and only a small portion require surgical intervention.
The key point here is determining which patients need surgery and which techniques can be used to control pain in patients who do not require surgery. Non-surgical methods include:
- Strong painkillers and rest therapy: Used to control pain and reduce inflammation.
- Physical therapy methods: Includes exercises and manual therapy practices to strengthen muscles, increase flexibility, and relieve pain.
- Injection treatments by experienced pain management specialists: Steroid and local anesthetic injections are administered around the nerve root, always under imaging guidance.
These methods are the most effective non-surgical treatment options for patients, and 90% of patients recover with these approaches.
Conditions Requiring Immediate Surgery for Lumbar Herniated Disc
These include:
- Progressive muscle weakness leading to paralysis: Weakness in the leg muscles with the risk of progressing to paralysis over time.
- Foot drop, where the patient is unable to lift the foot against gravity: Weakness and drooping of the foot due to paralysis of the tibialis anterior muscle.
- Loss of bladder and bowel control: Loss of control over urination and defecation due to paralysis of the sphincter muscles.
How Long Should Non-Surgical Methods Be Tried for Patients with Lumbar Herniated Disc?
This is a debated topic and, in general, non-surgical methods can be tried for up to 6 months. The key factor is how much the patient can tolerate the pain and how much this pain affects their daily activities. In some patients, the pain may remain at a manageable level with the non-surgical methods mentioned earlier, while in others, unbearable pain can persist for an extended period.
Therefore, waiting for 6 months in patients who do not benefit from non-surgical treatments may not be the best decision for patient comfort and quality of life. Surgical treatment can be considered earlier in these cases.
When Is Emergency Surgery Necessary for Lumbar Herniated Disc?
If patients present with foot drop or loss of bladder and bowel control, and these symptoms have recently developed, emergency surgery should be planned within 24-48 hours. Early intervention is critical, as these neurological findings may become permanent if not treated promptly.
Do Very Large Lumbar Herniated Discs Always Require Surgery?
The presence of a very large herniated disc as seen in radiological imaging is not necessarily an indication for immediate surgery. However, these patients should be warned and educated about the risk of developing neurological deficits, and muscle strength should be monitored at frequent intervals. The decision for surgery should be based on the patient's response to non-surgical treatments.
What Techniques Are Used in Lumbar Herniated Disc Surgeries?
The following two techniques are commonly used in lumbar herniated disc surgery:
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Microscopic Discectomy: This method, performed through a 3-4 cm skin incision under a microscope, remains the gold standard treatment for surgical management of lumbar herniated discs.
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Endoscopic Minimally Invasive Techniques: These methods have become increasingly common in recent years both in treatment and in scientific literature. When performed by experienced surgeons, the outcomes of endoscopic surgeries are comparable to those of microscopic surgeries. Each has its own advantages and disadvantages.
In the fully closed method known as percutaneous endoscopic lumbar transforaminal discectomy, patients were found to have better lower back pain scores in the first week compared to other techniques. However, long-term scores were found to be the same for both techniques. Additionally, post-surgical pain due to nerve root irritation was reported to be higher compared to microscopic discectomy. The experience of the surgeon performing the endoscopic surgery is critical, as complication rates decrease with increased experience.
The position of the herniated disc within the canal also affects the choice of surgical technique. Endoscopic techniques are more advantageous for far lateral or lateral disc herniations, while microscopic surgery is more favorable for centrally located, particularly calcified (hardened) discs. In both types of surgery, outcomes are successful when performed by experienced surgeons.
Can a Herniated Disc Recur After Surgery?
Yes, it can recur. However, the recurrence rate varies depending on the structure of the disc, generally ranging between 1-4%. Some scientific publications report higher rates. In cases where the disc structure is severely damaged, the risk of recurrence is higher.
Does the Disc Repair Itself After Surgery?
During surgery, the herniated disc material is removed. The remaining disc tissue heals the space with fibrous tissue, which is not the original disc tissue. Since the disc tissue lacks blood supply, its self-repair capability is limited. A herniated disc never fully returns to its original state.