The term “ruptured disc” is often heard, and it is often assumed that whenever there is low back pain, there is a ruptured disc. However, it is not common to see a herniated nucleus pulposus (a proprietary medical term) in the true sense of the word. What is a herniated disc? How does it produce symptoms? How is it diagnosed? What are the available treatments? Anatomy In order to understand your symptoms and treatment options, it is important to understand the anatomy of your low back. This includes the different structural components that make up the lumbar spine and how these tissue components work together. The intervertebral disc is a cushion between each vertebra in your spine that acts as a shock absorber. There is a disc between every two vertebrae, and each disc is surrounded by an outer layer of strong fibrous tissue called the annulus fibrosus; there is also a soft, jelly-like inner core called the nucleus pulposus. The annulus fibrosus is the outer layer of the disc, which appears as a lamina and is the strongest part of the disc. In fact, the annulus fibrosus is also a strong ligament that holds the two vertebrae together. The nucleus pulposus, on the other hand, is located in the center of the disc and is the main device for absorbing external shocks. A disc herniation occurs when the outer fibrous layer of the disc between the vertebral bones (the annulus fibrosus) is damaged and the inner soft nucleus pulposus tissue is removed from its normal location. If the torn annulus fibrosus is close to the spinal canal, then there is a possibility of the nucleus pulposus tissue entering the spinal canal. Etiology Herniation of the nucleus pulposus tissue is most common in young and middle-aged adults, and is rare in children. As a person ages, the spine also undergoes degenerative changes, and this can develop into a herniated disc. This is because the nucleus pulposus in the center of the disc gradually dehydrates and hardens, forming a degenerated nucleus pulposus, which can easily be “squeezed out” from the disc under pressure. The disc can rupture due to a certain amount of pressure. For example, a fall from a ladder or chair can cause a large force to be applied to the spine. If this force is large enough, the vertebrae may fracture or the disc may rupture. Bending over will also have a greater force acting on the discs. If you bend over to lift something too heavy, this force can also cause the disc to rupture. Discs can also rupture from the accumulation of smaller forces, usually because the annulus fibrosus becomes weak due to repetitive small injuries over time, and bending or lifting very light weights can cause the annulus fibrosus to tear and the nucleus pulposus to protrude. A herniated disc can produce symptoms in two ways. First, the herniated nucleus pulposus enters the body’s spinal canal causing greater pressure on the nerve causing symptoms; second, the nucleus pulposus produces a strong chemical irritation of the nerve root causing symptoms. Sometimes these two mechanisms combine to stimulate the nerve roots of a person, and then cause pain, weakness, numbness, and other symptoms in the area where the nerve roots are located (e.g., lower extremities). Symptoms A true herniated disc may not have symptoms of low back pain. The symptoms of a lumbar disc herniation are caused by compression or irritation of the nerves. But many people do have low back pain, and this is because when the disc ruptures there are other problems. Symptoms of a lumbar disc herniation usually include: radiating pain in one or both lower extremities numbness or tingling in one or both lower extremities weakness in some muscles in one or both lower extremities loss of tendon reflexes in one or both lower extremities These symptoms occur as a result of irritation of a single or multiple nerves in the lumbar spine. Therefore, it is helpful to diagnose the localization of the symptoms that appear, and the localization of the pain as determined by the physician will help determine which disc may be ruptured. Diagnosis A complete history and physical examination is required to diagnose a lumbar disc herniation. Your doctor will first ask you to confirm whether you have difficulty urinating or defecating. If so, this suggests that the lumbar disc has compressed the spinal cord, which requires emergency surgery to relieve the spinal cord compression. Diagnostic tests X-rays Your doctor will recommend that you have a lumbar spine X-ray. A routine x-ray will not show a herniated disc, but an x-ray will give your doctor information about the extent of degeneration and damage to your lumbar spine. Magnetic Resonance Imaging Magnetic resonance imaging is the most common test used to diagnose herniated discs. The test is painless and accurate and has no side effects. When there is a suspected herniated disc, MRI can serve as a substitute for other tests. CT scans Sometimes X-rays and MRI do not show all parts of the disease, and CT scans or CT with myelography are ways to provide more valuable information. Discography When a herniated disc is considered, the physician will recommend surgery. The doctor will also perform a discogram to clearly locate the disc causing the pain. Treatment options Conservative treatment How a herniated disc is treated is based on the symptoms you are experiencing. If your symptoms gradually improve, your doctor may recommend that you continue to be observed. If your symptoms continue to worsen, your doctor may recommend surgery. Most patients experience symptom relief after several weeks or months of conservative treatment. Observation If your symptoms do not progress, then you may not need further treatment, just observation. If the pain is tolerable and the symptoms of nerve or spinal cord compression are not getting worse, your doctor may recommend observation. Pain medication Depending on the severity of your pain, your doctor may give pain medication, including ibuprofen as well as new anti-inflammatory pain medications. They should be used as prescribed by your doctor. If the pain is not controlled by pain medication, your doctor may use a more potent pain medication, such as one with narcotic properties. It should be noted that narcotic pain medications should not be used for more than 1-2 weeks. Rest If the pain is very moderate, it is necessary to rest and reduce the usual level of activity. Your doctor may recommend that you wear a lumbar brace to limit the movement of your lumbar spine. After two or three days, you will be able to start moving around, starting with gentle activities and gradually increasing the amount of activity each day. Epidural block treatment Epidural blocks are usually used for patients with severe nerve root pain due to a herniated disc. If the condition is severe enough to require surgical treatment, epidural block therapy should not be performed. Epidural block therapy will be effective in about half of patients with herniated discs. Surgical treatment Surgical treatment is for patients with more severe symptoms, such as those who have had ineffective conservative treatment for 8-12 weeks and have recurrent pain and numbness in the lower extremities that severely affect their quality of life. Patients who develop incontinence must undergo immediate surgical treatment. About complications Just like with any other surgery, there are complications associated with surgical treatment in the lower back. Because the surgeon is performing surgery around the nerves and spinal cord, there are some potential risks. You should talk to your doctor to clarify where the risks of the surgery are and you should clarify where the benefits you can get from the surgery are.