Lumbar herniated intervertebral disc is a disease that causes low back pain and neurological symptoms due to the protruding intervertebral disc.
The most prominent symptom in patients with lumbar herniated intervertebral disc is radiating pain with numbness in the legs along with low back pain. The prolapsed intervertebral disc stimulates the nerve roots, resulting in paresthesia in the legs where the nerve roots are distributed. When the 5th lumbar nerve root is affected, the inner instep complains of sensory abnormalities, and when the first sacral nerve root is stimulated, the outside of the instep complains of sensory abnormalities. It usually complains of decreased sensation or numbness, but it also appears as hyperalgesia. Muscle strength is also weakened, so when the fifth neuromuscular disease is affected, the extensor of the foot is weakened, and it becomes difficult to walk with the heel at this time. In rare cases, if the protruding nucleus is large and located in the center, impaired stool control, sexual dysfunction, and leg paralysis may occur.
Unlike other musculoskeletal systems, degenerative changes in the spine appear from the late teens or early twenties. As the intervertebral disc ages, circumferential fissure and radial tear occur in the fibrous ring surrounding the edge of the intervertebral disc. In particular, when a heavy object is to be lifted and moved to the side, the nucleus in the center of the intervertebral disc is no longer located in the fibrous annulus due to excessive force in the excessively bent state, and it squeezes through the radial cracks, causing intervertebral disc herniation.
The diagnosis of intervertebral disc herniation can be done through medical examination and radiographic examination. A typical physical test for diagnosing disc herniation is a straight leg elevation test (a test in which the knee is stretched in an upright position looking at the ceiling, and the painful leg is slowly raised until the hip joint is 90 degrees). When lying down immediately and gradually raising the leg with the knee straight, the test result is positive if the painful leg cannot be lifted compared to the normal side due to the occurrence of pain that extends as if electricity flows behind it. In addition, the sensation and muscle strength of the leg decreases, and the deep tendon reflex is abnormal, resulting in the loss of the patellar tendon reflex or the Achilles tendon reflex.
First of all, a simple radiographic examination is performed. There are no specific findings for diagnosing disc herniation except for reduction of normal lumbar curvature in simple radiographic examination, but it is a necessary test to discriminate other diagnoses.
Magnetic resonance imaging (MRI) has the highest diagnostic value. However, not all intervertebral disc herniation patients must be subjected to magnetic resonance imaging. This is because it is possible to diagnose disc herniation to some extent by only a medical examination, and 80-90% of all patients heal well with conservative treatment for about 1-2 months. Therefore, it is recommended to perform conservative treatment once there is a symptom of herniated intervertebral disc, and to perform additional tests when the diagnosis is unclear or when surgery is necessary.
Treatment methods for herniated intervertebral discs can be divided into conservative and surgical methods. When choosing a treatment method, the following conditions should be considered comprehensively.
- Duration of symptoms
- Intensity of pain
- Number of recurrences
- Patient’s occupation, age, sex, workload, etc.
1) Conservative treatments
Conservative treatments include:
- Absolute bed rest
- Anti-inflammatory painkillers
- Pelvic traction
- Heat therapy
- Ultrasound therapy
- Transcutaneous electrical nerve stimulation (TENS)
- Wearing a brace
- Epidural steroid injection
- Exercises to strengthen the abdominal muscles
- Training on proper use of the lower back
Absolute bed rest is helpful in cases of acute symptoms, but it is best not to exceed a week. Pelvic traction is used as a symptomatic treatment of overall low back pain, which maximizes the effect of bed rest and reduces the pressure applied to the intervertebral disc. If possible, start walking with a brace as soon as the acute pain disappears. However, long-term wear of the brace causes muscle atrophy, so abdominal and back muscles must be exercised in parallel.
It should be noted that performing surgery without sufficient conservative treatment is likely to result in over-treatment.
2) Surgical treatments
Surgical treatment is performed in the following cases.
- If conservative treatment has been performed for 6 to 12 weeks and unbearable pain persists
- If lower limb paralysis does not improve or progresses
- If symptoms of stool disorder occur
- If the pain recurs frequently and it interferes with daily life
When the main symptom is not radiating pain in the lower extremity caused by nerve root stimulation, but only low back pain, the symptom does not improve much even after discectomy surgery.
As for the surgical method, there are minimally invasive surgery from the classical method of surgery after incision, and the minimally invasive surgery includes the following.
- Nucleus resection under a surgical microscope
- Endoscopic nucleus resection
- Automatic percutaneous nucleus resection
- Laser-assisted nucleus resection
- Chemical nucleus lysis, in which a drug is injected into the nucleus (This method has been decreasing in recent years.)
Progress and complications
Lumbar pain and radiating pain due to herniated intervertebral discs usually improve on their own over time, regardless of the method of treatment. This is because the inflammatory response disappears over time and the size of the nucleus decreases. It is also due to the characteristic of the living body that the length of the nerve root becomes longer when the nerve root is pressed continuously. Therefore, the basis of treatment is how comfortable the patient is until the symptoms disappear naturally.
After the acute symptoms disappear, abdominal exercises are needed to prevent recurrence. Surgical treatment should be approached with the concept that it is performed only when pain control is difficult.
Symptoms persist for more than 2 weeks in a very small number of patients with disc herniation.
Continuous lower back exercises are helpful in the treatment and prevention of low back pain and disc herniation. Aerobic exercise is good for about 20 to 30 minutes, such as walking on flat or low hills, cycling, and swimming (which is comfortable during freestyle or backstroke). Learning how to use your back properly and making it a habit as described above is also very important in preventing low back pain and disc herniation.
Living tips for patients with disc herniation
- Smoking is an important risk factor for low back pain or sciatica, so smokers should first stop smoking.
- Obesity is also a factor that increases the risk of disc herniation, so proper weight control is important.
- To prevent recurrence of low back pain and disc herniation, good posture on the back should be habituated.
- When lifting objects, always hold it close to the torso, keep the knees bent and the waist straight, and do not twist while bending the waist.
- When sitting, sit with your back straight on a chair with the back slightly tilted back. Sit deep in the chair and put your buttocks on the back of the chair, and get up and stretch once every 20 to 30 minutes. A chair with armrests on the chair is good. The height of the chair is good enough for your heels to touch the ground.
- When standing, put one foot on a low stool or box, and work with the worktable at a comfortable height.
- When driving, keep your seat close to the steering wheel, raise your knees, and support your back with a cushion.
- When sleeping, the floor should be relatively hard, but with some cushioning, and place a pillow under your knees or lie on one side to sleep.