Herniated Lumbar Disc

Herniated Lumbar Disc also known as Lumbosacral Radiculopathy (“slipped disc”, “ruptured disc”) is a medical term for the pain (lower back and legs), numbness, tingling and weakness associated with a herniated disc in the lumbar (lower back) region. Patients often undergo significant suffering and reduction in quality of life with this condition. It is the most common type of disc herniation. Lumbosacral disc herniation occurs in the lower back region, typically between the fourth and fifth lumbar (L4-L5) or fifth lumbar and first sacral (L5-S1) vertebral bodies but can occur in any disc of the lumbar spine. The essence of the condition is a tear in the fibrous outer ring of the disc between vertebrae which then allows for the central component (nucleus pulposus) to protrude out. This nucleus pulposus carries a cascade of inflammatory chemicals that often irritate and compress lumbar spinal nerves causing symptoms. This can occur spontaneously or from trauma, lifting, and straining of the lower back.

Symptoms of this condition depend on the location and severity of the herniation. In terms of location, there are five lumbar vertebral bodies with discs between them (these are the ones that can herniate) with 2 spinal nerves exiting at each level. Vertebral discs provide support and mobility for the lower back region. Severity is often caused by how much of the disc has herniated and subsequently compressed the surrounding lumbar spinal nerve. Patients’ symptoms can range from mild sensory changes in the lower back, buttock, thigh, foot or toe to numbness, tingling, paresthesia, sharp shooting pain, muscle weakness, and leg paralysis. Severe symptoms, including loss of bowel or bladder function, should warrant immediate medical evaluation.

Diagnosis and Management

Diagnosis of lumbar disc herniation is a clinical one often resulting from the history provided by the patient along with specific physical examination findings. Examination includes a thorough neurological examination to uncover motor, reflex, and sensory changes. This will often lead to the “culprit” lumbar nerve root that is affected by a lumbar disc herniation. Other signs include diminished leg reflexes and a positive straight leg raise. There is no “gold standard” for diagnosing lumbar disc herniation but often imaging, specifically MRI, is very helpful. Imaging may point to the existence of a specific location of disc protrusion. A positive correlation with symptoms may aid in the diagnoses. There is a high degree of variability in the symptoms experienced by patients. Most concerning is worsening pain and weakness in the leg. Other possible diagnoses for back/leg symptoms are lumbar facet syndrome, myofascial pain syndrome, and spinal stenosis.

Generally, lumbar disc herniations will heal on their own with conservative measures (including rest, ice, heat, anti-inflammatory medications). If symptoms do resolve, they often do in a period of weeks to a couple of months. Initial treatment involves conservative measures including education, light exercise, medications (a short course of anti-inflammatories), physical therapy, body mechanics, lumbar traction, and weight control. More invasive treatments include interventional pain injections (lumbar epidural steroid injections, spinal cord stimulation) and/or surgery (most commonly lumbar decompression or laminectomy). Lumbar epidural steroid injections involve depositing a small quantity of steroid and local anesthetic mediation, using X-ray image guidance, onto the affected lumbar spine nerve. These may often be repeated every 3-6 months depending on the symptoms. Indications for surgery include patients with ongoing leg pain despite 6-8 weeks of conservative treatment along with signs of motor or saddle weakness.