Prepared By: Ümit Bingöl, Associate Professor

What is lumbar disc herniation?

Lumbar disc herniation, is a burst out of the middle of the liquid part (nucleus pulposus) of   intervertebral disc (intervertebral disc) from surrounding structure (annulus fibrosus) (see figure below).

How much of the hernia is responsible for back pain?

As can be seen from the table below, the hernia is responsible for only 4% of the lumbar pain. The majority of low back pain develops as a result of excessive stress and strain in soft tissues (eg muscle) (70%).

Table 1. Causes of low back pain

• L Strain, sprain ----- 70%
• Degenerative changes ------ 10%
• Disc herniation ----- 4%
• Osteoporosis-induced compression fractures ---- 4%
• Spinal stenosis ----- 3%
• Spondilolistesis ----- 2%
• Spondylolysis, discogenic back pain or other instability ----- 2%
• Congenital diseases ----- <1%
• Traumatic fractures ------- <1%
• Cancer ------ 0.7%
• Inflammatory arthritis ----- 0.3%
• Infections ------- 0.01%

Why does a lumbar disc herniation often occur in the posterior or posterolateral of the disc?

Anulus fibrosis is the weakest in this region.

Exposure of the posterior section to more repressive, rotating and pulling-separating forces than the front.

Relatively inadequate nutrition in the posterior annulus.

Posterior location of the nucleus and spreading and thinning of the posterior long ligament at the disc level.

Where is hernia seen mostly?

90% of hernias occur in the lumbar region. The remaining occurs in the neck and back vertebrae. 

95% of the lumbar hernias occur at the L4-L5 and L5-S1 vertebrae. The reason is that this region is more mobile and subject to further loading. 

What are the symptoms of lumbar disc hernia?

The most significant complaint is pain. The pain usually starts from the waist or hips, spreading from the back of the leg to the heel and is called the sciatic pain. Often pain is more severe in the leg than in the waist.  Sensory disorders (burning, felting, numbness) may accompany pain. The pain increases with coughing, straining and laughing. Also standing, sitting and leaning forward increase pain. Depending on the level of hernia, loss of strength, loss of sensation or reflex may occur in patients. In some cases, dysfunction of urine and defecation control may develop. In such cases, emergency surgery is required.

What are the findings of physical examination?

Flattening occurs in the waist due to the contraction of the waist muscles. A curvature may develop in case of nerve root compression, this condition is called scoliosis. Muscles around the waist are stiff due to spasm. The forward bending movement is limited and painful. Sensory, strength and reflex losses, urinary and defecation control disorders can be detected.

Which imaging methods are used in the diagnosis?

The main diagnostic method for lomber disc hernia is a good history and examination. However, sometimes other imaging methods such as X-ray, computed tomography, magnetic resonance imaging and scintigraphy can be used for differentiating from other diseases.

Radiographic examinations are generally not necessary in patients with low back pain for less than 4 weeks. Direct radiographs have no place in the diagnosis of lomber disc herniation. However in case of infections, fractures, cancer, spondylolisthesis, degenerative changes, narrowing of the disc space and previously lumbar surgery, x-ray imaging may be useful. 

In recent years, it has been attempted to be diagnosed with herniated disc on the basis of only magnetic resonance imaging (MRI) method. However, it should be kept in mind that magnetic resonance imaging may present with hernia findings in 22-40% of the patients with no complaints. Computed tomography (CT) is similar. CT or MRI should be used if a physical examination by a physician is found to suggest an emergency condition (cauda equina syndrome, infection, tumor, fracture or mass with neurological loss).

Are there any conditions that require attention for diagnostic examination in patients with low back pain?

Patients with recent history of trauma, unexplained weight loss and fever, immunosuppressive therapy, cancer patients, intravenous drug use, osteoporosis, corticosteroid therapy, patients with progressive neurological deficits, patients with complaints lasting more than six weeks They should be evaluated with advanced tests and imaging methods.

Patients with recent history of trauma, unexplained weight loss and fever, immunosuppressive therapy, cancer, intravenous drug use, osteoporosis, corticosteroid therapy, patients with progressive neurological deficits, patients with complaints lasting more than six weeks should be evaluated with advanced tests and imaging methods.

What can be done in the treatment?

Various methods including rest, medication, muscle relaxants, epidural steroid injections, local anesthetics, antidepressants, physical therapy methods, exercise and surgery can be applied according to the patient's findings.

Rest

It can help relieve symptoms by reducing intra-disk pressure and loading in soft tissues around the vertebra. Bed rest has not been shown to be useful in the natural progress of low back pain. Besides, there are studies suggesting that long-term bed rest may have harmful effects.

The bed should not be hard enough to force the spine nor soft enough to collapse. The patient can lie on his back, right side and left side position. While lying on his back, the knees are half-curved and two cushions are under the knees; while lying on his side, the knees should be bent and the cushion is between two knees. 

The duration of bed rest started to be discussed in the 1980s. Deyo et al. showed that people who had 2-day bed rest returned to work faster than those who had bed rest for 7 days (N Engl J Med, 1996). Gilbert et al. have found that those who do not have bed rest returned to work faster than those who had bed rest for 4 days and that their daily activities are less restricted (Brit Med J, 1985). As a result, the scientific publications on the effectiveness of bed rest in acute low back pain are reviewed; it has been shown that the continuation of usual activity provides better improvement in the complaints according to drug treatment and bed rest. 

Medications

The aim of drug therapy in low back pain is to improve the complaints, to ensure movement and to facilitate return to active life and work. Antirheumatic drugs and muscle relaxants are used for this purpose.

Physical therapy and exercise

Cold-hot applications, massage, traction, TENS, electrotherapy, ultrasound, corsets and various supports are frequently used. During the prevention and treatment of lumbar disc hernia, follow-up of the physical medicine and rehabilitation specialist is necessary. 90/90 resting position, posterior pelvic tilt, hamstring stretching and trapeze exercises can be recommended according to the patient's findings (in the pictures below). For protective purposes, attention should be paid to proper postures in the daily life of sleeping, sitting, standing, stretching, bending, lifting and carrying positions (shown in the following pictures as true / false).

Can surgical treatment be needed?

Only 1-2% of patients with lumbar disc hernia require surgical treatment. Cauda equina syndrome (bladder urinary retention and bowel dysfunction, loss of sensation, numbness and weakness in both legs) and progressive neurological loss despite medical treatment and prevention require surgical treatment.