What Is Lumbar Disc Herniation?
We have 5 vertebral bones in our lumbar region. Between these vertebral bones, there are cushions called discs. These discs provide flexibility to the spine’s movements. Our lumbar spine allows us to bend forward, backward, sideways, and rotate. Lumbar disc herniation occurs when the disc between the vertebrae changes its position, causing pressure on the spinal cord and the nerve roots emerging from the spinal cord.
Can You Provide Information About The Frequency Of Lumbar Disc Herniation?
The frequency of lumbar disc herniation is about 1-2%. It is more common in men than in women. Disc herniation is often observed in the 30s and 40s when the structure inside the disc, known as the nucleus pulposus, has a gelatinous consistency. The most common area for disc herniation is the posterior and lateral part of the spine at the L4-L5 and L5-S1 levels.
What Symptoms Can Occur When There Is Lumbar Disc Herniation?
When lumbar disc herniation occurs, the symptoms vary depending on the structures affected (spinal cord and/or nerve roots). A person with lumbar disc herniation may present with pain, but in severe cases, they may also experience difficulty walking, leg weakness, and urinary incontinence. The distribution and impact of symptoms depend on the anatomical structures to which the nerve roots emanating from the level of the herniation send their branches.
The main symptoms include:
- Back pain: Typically sharp and stabbing, sometimes intermittent regional back pain attacks.
- Pain radiating from the lower back to the hip/leg: Reflecting the anatomical distribution of the affected nerve root.
- Tingling/numbness/pins and needles/loss of sensation in the back/leg.
- Restriction in back movements.
- Difficulty walking and sitting.
- Urinary incontinence or difficulty urinating.
- Balance-related complaints and falls.
Many patients describe suddenly feeling “locked” and unable to move. The pain is mechanical in nature. Sometimes, they may only complain of pain in a specific position; in lumbar disc herniation, bending forward typically exacerbates the pain, while moving the spine backward provides relief.
Movements that increase intraspinal pressure (such as coughing, sneezing, straining, stretching, sitting, driving, walking, laughing, getting up from bed, etc.) worsen the pain.
What Findings Do You Identify During The Physical Examination?
During the physical examination, we observe various findings in the patient. These include:
- Restriction in the movement of the patient’s lumbar region.
- Antalgic gait, where the patient walks without putting weight on the painful side, often by flexing the painful leg to reduce the load.
- Patients may exhibit a scoliotic posture, meaning they cannot stand upright and tend to lean to one side. They may also lean to the side when attempting to bend forward.
Additionally, sensory and motor losses are identified based on the affected nerve root:
- If the S1 nerve root is affected, there may be an inability to perform toe-raising movements, loss of sensation on the outside of the foot and calf, and a loss of the Achilles reflex.
- In the case of L5 nerve root involvement, there may be weakness in extending the big toe and sensory loss on the top of the foot.
- For L4 nerve root involvement, difficulty in heel-walking, loss of the patellar reflex, and sensory loss on the inner side of the ankle may be observed.
In the examination of the patient, both nerve tension tests are performed and the affected nerve level is determined by performing a complete neurological examination.
What Are The Risk Factors For Back Pain?
Some of the risk factors for back pain include:
- Sedentary jobs and lifestyles (office work, etc.)
- Heavy lifting
- Bending and making sudden movements
- Prolonged standing and sitting without changing positions
- Job dissatisfaction
- Long hours of driving (for example, among drivers)
- Being overweight
- Having weak back and abdominal muscles
- Working with vibrating tools
- Poor body mechanics and posture
- Engaging in high-risk sports (weightlifting, rowing, tennis, gymnastics, soccer, wrestling, skiing, etc.)
- Smoking (as it affects disc nutrition and can lead to frequent coughing)
- Psychosocial factors (somatization, anxiety, depression)
- Low socioeconomic status
- Genetic factors
Unfortunately, many of us lead a sedentary lifestyle. Prolonged sitting in front of a desk due to office work, for example, is a risk factor for developing back pain. It not only increases pressure but also disrupts the nutrition of that area.
Therefore, sitting in the correct position and taking short breaks from desk work at regular intervals are important for our back health.
What Information Is Valuable To You When A Patient With Back Pain Presents?
When a patient complains of back pain, I inquire about many aspects.
Some of these include:
- The onset, frequency, and duration of back pain.
- The location of the pain.
- Factors that trigger, exacerbate, or alleviate the pain.
- Morning stiffness.
- The effect of coughing, sneezing, or straining on the back pain.
- Timing of the pain throughout the day.
- The presence of nighttime pain.
- Any accompanying leg symptoms (pain, paresthesia, numbness, weakness, atrophy, etc.).
- Bladder and bowel problems.
- History of back surgery.
How Do You Determine If The Patient's Pain Is Due To Lumbar Disc Herniation?
Many of my patients come to me saying, “I have a herniated disc.” I always ask my patients to describe their complaints to me. It’s important to remember that we don’t make a diagnosis solely based on an X-ray or MRI. Finding a herniated disc on an imaging study doesn’t necessarily confirm that the pain is caused by the herniation.
In fact, unnecessary imaging can sometimes lead us in the wrong direction. Patients who have been told they have a herniated disc may automatically attribute their pain to it when they experience discomfort.
In patients presenting with pain in the back and/or leg regions, before diagnosing lumbar disc herniation (herniated disc), we need to rule out many other causes of pain, such as abdominal pain originating from abdominal organs (kidney stones, gallbladder issues, pancreatitis, endometriosis, pelvic inflammatory disease), vascular pathologies (aortic aneurysm, arterial blockages), cancer, and infectious diseases, as well as metabolic bone disorders (osteomalacia, fractures, etc.).
The correct diagnosis leads to the right treatment. Unfortunately, many patients come in with X-rays already taken, thinking, “I already know my diagnosis, just look at the film and treat me.” In reality, this can often mislead me.
What I need is for the patient to start by describing their current complaint, then provide a summary of how the issue started and the journey they’ve been on until now. This way, I can evaluate the path to diagnosis and treatment, and after my examination, chart a course of action based on what can be done moving forward.
From time to time, I even reevaluate my own patients. Medicine is not like mathematics; two plus two doesn’t always equal four. There’s no disease; there’s a patient.
Diseases progress differently from person to person. Initial symptoms can lead to entirely different diagnoses over time.
If a patient develops new symptoms or their existing symptoms worsen, they should definitely inform their doctor.
Some diseases can coexist. Initially, findings that suggest only a herniated disc may become overshadowed over time by symptoms that suggest secondary conditions like inflammatory rheumatism or bone disease.
I had a patient in their forties who had both a herniated disc and blockages in the main arteries going down their leg due to vascular issues, which had actually limited their ability to walk. Good communication, dedicating time to each other, and active listening are crucial.
We all need to analyze our own symptoms carefully. However, this shouldn’t lead us into a state of paranoia. We shouldn’t panic at the slightest discomfort and jump into a “Oh no, I’m getting worse” mode. Unfortunately, panicking doesn’t resolve pain; it can actually increase pain due to excessive muscle tension. Relaxation techniques are very effective in relieving muscle spasms.
After a thorough history and physical examination, I decide whether the patient needs to be further evaluated through laboratory tests and/or imaging methods. If the test results are consistent with the patient’s symptoms, I have completed the diagnostic phase and proceed to the treatment plan.
What Are The Causes Of Back Pain?
- Transitional vertebra
- Facet joint asymmetry
- Scoliosis, kyphosis
- Lumbar strain/sprain (70%)
Degenerative Diseases of the Spine (Lumbar Spondylosis) (10%)
- Discogenic pain
- Facet syndrome
- Combined disc and facet degeneration
- Disc Herniation (4%)
- Spinal stenosis (3%)
Spondylolysis, Spondylolisthesis (2%)
Compression Fractures (4%)
Thoracolumbar Junction Syndrome
Myofascial Pain Syndromes
Sacroiliac Joint Syndrome
- Primary vertebral tumor
- Spinal (extradural and intradural)
- Multiple myeloma
- Vertebral osteomyelitis and discitis
- Epidural abscess
Seronegative Spondyloarthropathies (0.3%)
Metabolic Bone Diseases
- Paget’s disease
- Gastrointestinal system (Cholecystitis, pancreatitis, peptic ulcer)
- Pelvic organs (prostatitis, endometriosis, pelvic inflammatory disease)
- Renal (nephrolithiasis, pyelonephritis, perinephric abscess)
- Aortic aneurysm
Which Imaging Method Is Preferred For Diagnosing Lumbar Disc Herniation?
Magnetic resonance imaging (MRI) of the lumbar region is the preferred method for diagnosing lumbar disc herniation. It is the diagnostic method that provides the clearest view of soft tissues.
What Other Laboratory And Imaging Methods Are Used?
The choice of diagnostic methods depends on the patient’s symptoms and the diseases considered in the differential diagnosis. Various tests can be conducted, including plain radiography, computed tomography (CT), MRI of other regions, electromyography (EMG) examinations, ultrasound, laboratory tests such as complete blood count and biochemistry, assessment of vitamin levels, and inflammation markers.
If there are no additional pathologies suspected in a new-onset back and/or leg pain, and no neurological deficits are present, the patient can be managed with conservative treatment alone. However, the presence of “red flags” in a patient warrants immediate further evaluation.
What Are "Red Flags"?
In the context of back pain, “red flags” include the following:
- Age > 50, especially in women with osteoporosis or men with compression fractures.
- Age > 70.
- Unexplained fever, urinary, or other infection history.
- Unexplained weight loss.
- Trauma, cumulative trauma.
- Night pain.
- Cauda equina syndrome (saddle anesthesia, urinary or fecal incontinence).
- History of osteoporosis.
- History of cancer or strong suspicion of cancer.
- Prolonged use of corticosteroids.
- Intravenous drug use.
- Immunosuppression or diabetes mellitus.
- Progressive or focal neurological deficit accompanying disability symptoms.
- Back pain lasting longer than 6 weeks.
- History of previous surgery.
How Is The Recovery Process For Acute Lumbar Disc Herniation?
In approximately 75% of patients, improvement is typically seen within 3 months.
What Are The Treatment Approaches For Lumbar Disc Herniation?
In patients without “red flags,” initial treatment includes conservative approaches such as medical treatment, physical therapy, bracing, and organizing daily activities to keep the patient active.
Is Bed Rest Recommended For Lumbar Disc Herniation?
This topic is highly debated. It is generally better to remain active at the pain-free threshold rather than opting for bed rest. However, in cases of severe leg pain, short-term (2-7 days) bed rest may be considered. The patient’s resting position should be without pain. It is recommended for the patient to lie on their back or on their side.
In a supine position, placing a pillow under the knees to keep them bent and, in a lateral position, using a pillow between the knees to maintain a slight bend can reduce intra-abdominal pressure and provide a pain-free position. A prone position is usually not comfortable. However, some patients cannot fall asleep in any position other than prone.
For them, my recommendation is to place a thin pillow under the abdomen and a thin pillow under the legs to try to find a pain-free position.
It’s important for bed rest to be short-term because extended bed rest can lead to increased pain due to edema in the affected area. Getting up from bed increases intra-abdominal pressure and can worsen the pain. When getting up from bed, it is recommended to roll onto your side, let your feet hang off the edge of the bed, and then slowly sit up.
Sitting with a slight backward tilt and supporting the lower back with a pillow can be comfortable. Be cautious when sitting down or getting up from a chair, and avoid excessive forward bending while moving.
Can You Provide Information On The Use Of A Brace In Lumbar Disc Herniation?
In patients with lumbar disc herniation, we often use lumbosacral or lumbostadt braces. The purpose of using a brace is to reduce pain, prevent the progression of damage, and prevent deformity.
Braces restrict lumbar movements, reduce the axial load on the disc, decrease lumbar curvature, and encourage the patient to move within a pain-free range while reminding them of their condition.
Braces should be worn in a lying position, during the day, and can be removed if the patient does not get up at night. The brace can be loosened after eating.
There is no clear data regarding the duration of brace usage. The most significant concern with brace usage is that it may lead to muscle weakness. However, recent data suggest that even long-term usage does not necessarily cause muscle weakness.
Patients who experience leg pain often report that their leg pain decreases while their back pain increases when wearing a brace. This is a common observation during various treatment approaches. When significant compression on the nerve root begins, back pain may decrease, and leg pain may become more prominent.
Conversely, when pressure on the nerve root decreases, back pain may be more intensely felt. This is a typical progression observed during treatment.
What Treatments Are Performed In Physical Therapy?
In physical therapy, some of the methods used include superficial/deep heat applications, pain-relieving electrical currents (electrotherapy), traction, manipulation, massage, and exercise applications. The goal of physical therapy is to relieve pain, reduce inflammation and edema, relax muscles, reduce the size of the herniation, normalize intra-abdominal pressure, and increase spinal stability.
Patients with lumbar disc herniation can apply localized superficial heat at home to the lumbar area. However, it’s essential to avoid overheating or lying directly on a hot surface, as this can lead to burns.
Deep heat applications are performed in physical therapy clinics using ultrasound and shortwave devices. These devices create heat deep within the tissues, aiming to expedite the resolution of edema and inflammation and promote nerve healing.
Can You Tell Me About The Role Of Exercise In Treatment?
Exercise is a crucial component of treatment and the prevention of recurrent back pain. During periods of pain, restricted movement can lead to abdominal muscle weakness and shortening of the muscles in the back. The goal of exercise therapy is to restore joint biomechanics, prevent the development of chronic pain, avoid recurrences, and, in turn, enhance physical function.
Exercise helps improve muscle strength, endurance, flexibility, and joint range of motion while preventing contractures and restoring joint biomechanics. It stimulates the release of endorphins and increases localized blood flow. Improved blood flow enhances the nutrition of the discs and muscles, relieves muscle spasms, alleviates depression, and boosts self-confidence.
Exercises should become a habit and be performed regularly for their maximum effectiveness. It’s essential to remember that the full benefits of exercise may become more apparent after at least three months of consistent training. Exercises should not induce pain; there may be a slight feeling of stretching or discomfort.
If pain occurs during exercise, it could be due to improper technique or attempting an exercise too soon. Warm-up exercises should precede exercise routines, and stretching and relaxation exercises should follow. Without proper warm-up and cool-down, there is a higher likelihood of experiencing pain during exercise, and the exercise session might result in harm rather than benefit.
After exercise, there may be mild muscle soreness for a short time, but if severe pain occurs, it’s essential to reconsider the exercise routine. It’s recommended to start with the least strenuous movements, which are often ground exercises.
Are There Specific Exercises For Lumbar Disc Herniation?
Yes, there are. McKenzie exercises and lumbar stabilization exercises are particularly recommended. In McKenzie exercises, repetitive joint movement exercises are performed based on identifying the position that provides the most pain relief. Initially, pain may increase with these movements, but if the pain centralizes to the back, it usually indicates a positive response to treatment.
In dynamic stabilization exercises, patients are taught a neutral spinal position, and they are encouraged to maintain this position during daily activities to reduce repetitive microtraumas. In addition to these exercises, aerobic exercises, especially walking and swimming, are recommended.
If a person cannot perform any exercise, it’s important for them to walk as much as they can tolerate. When I mention walking, I’m not referring to a one-hour walk; as I emphasized earlier, short-duration, frequent exercises are often better than a single intense exercise session. Starting with a short walk (e.g., 15 minutes) on a relatively flat surface with suitable shoes and gradually increasing the distance if there is no increase in pain is a more suitable approach.
I understand that you might say, “I can’t go out, my house has stairs, and it’s challenging to go up and down during this period; I don’t have a place to walk.” In that case, you can walk indoors for 5-10 minutes every hour. Everyone should create the most suitable option for themselves. “I can never do it” should not be an acceptable choice.
When Is Emergency Surgery Necessary For Lumbar Disc Herniation?
The choice and timing of surgical treatment are subjects of debate. Unless emergency surgery is required, conservative treatment is generally recommended for the first 6 weeks. Emergency surgical indications, aside from cauda equina syndrome, include progressive neurological deficits (worsening motor and sensory loss) and uncontrolled pain despite other treatments.
The size or compression status of the existing disc herniation alone is not a sufficient criterion for deciding on surgery. The most crucial factors in deciding on surgical treatment are clinical examination findings.
Close monitoring and self-assessment by the patient are important. Emergency surgery is necessary when new neurological deficits develop. In surgical treatment, cases with both back and leg pain tend to yield more successful results compared to cases with only back pain.
The primary goal of surgical treatment is to prevent permanent neurological damage and facilitate the patient’s quicker return to normal life.
Will A Patient Who Undergoes Surgery For Lumbar Disc Herniation Be Completely Rid Of The Herniation?
This is a question I encounter quite often. Unfortunately, having surgery for a disc herniation does not guarantee that you will never experience this problem again. In many cases, we find multiple herniations in the same person simultaneously.
Individuals with a genetic predisposition to herniation can develop new herniations in other spinal regions and even in the operated area.
Herniation in the spine can lead to biomechanical changes in the spine, which can result in wear and tear in other spinal levels over time. If a person does not take precautions, engage in exercises, and disregards minor traumas, they may encounter herniation again after a while.
Can A Lumbar Disc Herniation Disappear Without Surgery?
With non-surgical conservative treatment, there can be a reduction in the size of the disc herniation, and this reduction is more significant in larger herniations. Surgical treatment helps alleviate pain more rapidly, but when compared to conservative treatment, after 2 years, there is no significant difference in terms of pain intensity.
Can You Provide Some Information About The Injection Methods Used In Lumbar Disc Herniation?
These methods are preferred in cases where patients continue to experience back and leg pain despite conservative treatment. Generally, they are not the first choice in treatment. Various injection methods are used, including paravertebral, paraspinal, intrathecal, intradiscal, and epidural applications.
What Complementary Medical Methods Can Be Applied For Lumbar Disc Herniation?
Complementary medical methods like mesotherapy, neural therapy, prolotherapy, cupping therapy, leech therapy, ozone therapy, manipulations, and chiropractic treatments can be used in treatment. However, I would like to emphasize that it is not appropriate to resort to these treatments without proper examination and a correct diagnosis.
Treatment is important, but first, a correct diagnosis must be established. Otherwise, expecting benefits from treatment may not be accurate. Complementary medical methods should be administered by qualified individuals who have received the necessary training in this field to ensure safe and correct treatment.
What Can Be Done To Prevent Lumbar Disc Herniation?
This is a topic I consider very important. Living a healthy life is something we all desire, but it doesn’t happen without effort. What should we do?
In today’s mandatory training, workplaces provide information on how to take care of one’s spinal health. It’s essential to take these training sessions seriously and implement what you learn.
Incorporating regular exercise into our daily lives and staying away from smoking are also essential preventive measures.
Lastly, What Would You Like To Say About Lumbar Disc Herniation?
Unfortunately, after the painful condition passes, we tend to forget the pain quickly and immerse ourselves in life as if we were never ill. It’s crucial to make preventive measures a part of our lives after an illness. One common mistake is discarding a habit or a situation we realize is problematic by saying, “I can’t change this situation anyway.” There is always a solution if we are willing to find it. Let’s put forth effort now for peaceful and healthy days