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Herniated disc

(Slipped or Bulging Disc)

Overview

What is a herniated disc?

A herniated disc refers to a problem with one of the rubbery cushions, called discs, that sit between the bones that stack to make the spine. These bones are called vertebrae.

A spinal disc has a soft, jellylike center called a nucleus. The nucleus is encased in a tougher, rubbery exterior, known as the annulus. A herniated disc occurs when some of the nucleus pushes out through a tear in the annulus. A herniated disc is sometimes called a slipped disc or a ruptured disc.

A herniated disc, which can occur in any part of the spine, most often occurs in the lower back. Depending on where the herniated disc is, it can result in pain, numbness or weakness in an arm or a leg.

Many people have no symptoms from a herniated disc. For people who do have symptoms, the symptoms tend to improve over time. Surgery is usually not needed to relieve the problem.

Other names for a herniated disc include:

Bulging disc.

Slipped disc.

Ruptured disc.

Protruding disc.

Symptoms

Most herniated discs occur in the lower back, but they also can occur in the neck. Symptoms depend on where the disc is sitting and whether the disc is pressing on a nerve. Herniated discs often affect one side of the body.

Arm or leg pain. If your herniated disc is in your lower back, you'll typically feel pain in your lower back, buttocks, thigh and calf. You might have pain in part of your foot as well.

For a herniated disc in your neck, you'll typically feel the most pain in your shoulder and arm. This pain might shoot into your arm or leg when you cough, sneeze or move into certain positions. Pain is often described as sharp or burning.

Numbness or tingling. People who have herniated discs often have radiating numbness or tingling in the body part served by the affected nerves.

Weakness. Muscles served by the affected nerves tend to weaken. This can cause you to stumble or affect your ability to lift or hold items.

You can have a herniated disc without symptoms. You might not know you have it unless it shows up on a spinal image.

When to see a doctor

Seek medical care if your neck or back pain travels down your arm or leg, or if you also have numbness, tingling or weakness.

Causes

Each disc in your spine has a soft, gel-like center and a firmer outer layer, kind of like a jelly doughnut. With time, the outer layer weakens and can crack. A herniated disc happens when the inner “jelly” substance pushes through the crack and presses on your spinal cord. The leaked material may press on nearby spinal nerves, causing the symptoms of a herniated disc.

Several factors can contribute to a disc rupture. Herniated disc causes include:

Aging.

Traumatic injuries, like falls.

Performing repetitive bending or twisting motions.

Improper lifting of heavy objects.

Risk factors

Factors that can increase the risk of a herniated disc include:

Weight. Excess body weight causes extra stress on the discs in the lower back.

Occupation. People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also can increase the risk of a herniated disc.

Genetics. Some people inherit a predisposition to developing a herniated disc.

Smoking. It's thought that smoking lessens the oxygen supply to discs, causing them to break down more quickly.

Frequent driving. Being seated for long periods combined with the vibration from a motor vehicle engine can put pressure on the spine.

Being sedentary. Regular exercise can help prevent a herniated disc.

Complications

Just above your waist, your spinal cord ends. What continues through the spinal canal is a group of long nerve roots that resembles a horse's tail, called the cauda equina.

Rarely, disc herniation can compress the entire spinal canal, including all the nerves of the cauda equina. In rare instances, emergency surgery might be needed to avoid permanent weakness or paralysis.

Seek emergency medical attention if you have:

Worsening symptoms. Pain, numbness or weakness can increase to the point that they hamper your daily activities.

Bladder or bowel dysfunction. Cauda equina syndrome can cause incontinence or trouble urinating even with a full bladder.

Saddle anesthesia. This progressive loss of sensation affects the areas that would touch a saddle — the inner thighs, the backs of the legs and the area around the rectum.

Prevention

To help prevent a herniated disc, do the following:

Using proper lifting techniques. Don’t bend at the waist. Bend your knees while keeping your back straight. Use your strong leg muscles to help support the load.

Maintain good posture. This reduces pressure on your spine and discs. Keep your back straight and aligned, particularly when sitting for long periods. Lift heavy objects properly, making your legs — not your back — do most of the work.

Maintain a healthy weight. Excess weight puts more pressure on the spine and discs, making them more susceptible to herniation.

Stretching. It’s especially important to take stretching breaks if you often sit for long periods.

Avoiding wearing high-heeled shoes. This type of shoe throws your spine out of alignment.

Getting regular physical activity. Focus on workouts that strengthen your back and abdomen muscles to help support your spine.

Quit smoking.Smoking can weaken discs, making them vulnerable to rupture. Consider quitting smoking.

Diagnosis

During the physical exam, your health care professional will check your back for tenderness. You might be asked to lie flat and move your legs into various positions to help determine the cause of your pain.

Your doctor also may perform a neurological exam to check your:

Reflexes.

Muscle strength.

Walking ability.

Ability to feel light touches, pinpricks or vibration.

In most cases of herniated disc, a physical exam and a medical history are all that are needed for a diagnosis. If your health care professional suspects another condition or needs to see which nerves are affected, you may have one or more of the following tests.

Imaging tests

X-rays. Plain X-rays don't detect herniated discs, but they can rule out other causes of back pain. X-rays can show an infection, a tumor, spinal alignment issues or a broken bone.

CT scan. A CT scanner takes a series of X-rays from different directions. Those images are combined to create cross-sectional images of the spinal column and the structures around it.

MRI. Radio waves and a strong magnetic field are used to create images of the body's inner structures. This test can be used to confirm the location of the herniated disc and to see which nerves are affected.

Myelogram. A dye is injected into the spinal fluid before a CT scan is done. This test can show pressure on the spinal cord or nerves due to multiple herniated discs or other conditions.

Nerve tests

Nerve conduction studies and electromyograms (EMGs) measure how well electrical impulses are moving along nerve tissue. This can help pinpoint the location of nerve damage.

Nerve conduction study. This test measures electrical nerve impulses and functioning in the muscles and nerves through electrodes placed on the skin. The study measures the electrical impulses in nerve signals when a small current passes through the nerve.

Electromyogram (EMG). During an EMG, a doctor inserts a needle electrode through the skin into various muscles. The test evaluates the electrical activity of muscles when contracted and when at rest.

Treatment

Conservative treatment includes changing activities to stay away from movement that causes pain and taking pain medicines. This treatment relieves symptoms in most people within a few days or weeks.

Medications

Nonprescription pain medicines. If your pain is mild to moderate, your health care professional might recommend nonprescription pain medicine. Options include acetaminophen (Tylenol, others) ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve).

Neuropathic drugs. These drugs affect nerve impulses to decrease pain. They include gabapentin (Horizant, Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), or venlafaxine (Effexor XR).

Muscle relaxers. You might be prescribed these if you have muscle spasms. Sedation and dizziness are common side effects.

Opioids. Because of the side effects of opioids and the potential for addiction, many health care professionals hesitate to prescribe them for disc herniation. If other medicines don't relieve your pain, your health care professional might consider short-term use of opioids. Codeine or an oxycodone-acetaminophen combination (Percocet) may be used. Sedation, nausea, confusion and constipation are possible side effects of these medicines.

Cortisone injections. If your pain doesn't improve with oral medicines, your health care professional might recommend a corticosteroid injection. This medicine can be injected into the area around the spinal nerves. Spinal imaging can help guide the needle.

Therapy

Your health care team might suggest physical therapy to help with your pain. Physical therapists can show you positions and exercises designed to minimize the pain of a herniated disc.

Surgery

Herniated discs get better on their own or with nonsurgical treatment for 9 out of 10 people. If other treatments don’t relieve your symptoms, your healthcare provider may recommend surgery. There are multiple surgical techniques for relieving pressure on your spinal cord and nerves.

In rare cases, a large ruptured disc might injure nerves to your bladder or bowel. That may require emergency surgery. For non-emergency cases, herniated disc surgery is an option when other treatments don’t work. There are various ways to perform spinal decompression surgery, but the goal is to relieve pressure on your nerves.

The most common procedure is called a microdiscectomy. With this minimally invasive spine surgery, your provider will make a small cut (incision) through the skin near the slipped disc. They’ll insert a microscope and small tools through the incision to remove the herniated part of the disc.

Other surgical treatment options include:

Discectomy.

Laminotomy.

Laminectomy.

Artificial disc surgery.

Spinal fusion.

Lifestyle and home remedies

Besides taking the pain medicines your health care professional recommends, try:

Applying heat or cold. At first, cold packs can be used to relieve pain and swelling. After a few days, you might switch to gentle heat to give relief and comfort.

Avoiding too much bed rest. Staying in bed can lead to stiff joints and weak muscles — which can complicate your recovery. Instead, rest in a position of comfort for 30 minutes, and then go for a short walk or do some work. Try to avoid activities that worsen your pain.

Resuming activity slowly. Let your pain guide you in resuming your activities. Make sure your movements are slow and controlled, especially bending forward and lifting.

Alternative medicine

Some alternative and complementary medicine treatments might help ease chronic back pain. Examples include:

Chiropractic. Spinal manipulation has been found to be moderately effective for low back pain that has lasted for at least a month. Rarely, chiropractic treatment of the neck can cause certain types of strokes.

Acupuncture. Although results are usually modest, acupuncture appears to ease chronic back and neck pain.

Massage. This hands-on therapy can provide short-term relief to people dealing with chronic low back pain.

Prognosis

How long does it take to recover from a herniated disc?

For the majority of people, herniated disc pain gets better on its own or with simple medical care. You’ll probably feel better within a month. If you don’t, you should see a healthcare provider. Some people need more aggressive medical measures, like spinal injections or herniated disc surgery.

Will a slipped disc get worse?

An untreated herniated disc can get worse. That’s especially true if you continue the activities that caused it — for instance, if it developed because of your work. A worsening ruptured disc may cause chronic (ongoing) pain and loss of control or sensation in the affected area. See a healthcare provider if you still have symptoms after four to six weeks of conservative care.

Living With..

When should I see my healthcare provider?

Initially, you can treat ruptured disc pain at home. But you should see a healthcare provider if:

Pain interferes with daily life, like going to work.

Symptoms aren’t better after four to six weeks.

Symptoms get worse.

You develop loss of bladder or bowel control.

You notice tingling, numbness or loss of strength in your arms, hands, legs or feet.

You have trouble standing or walking.

What questions should I ask my healthcare provider?

Questions to ask your provider include:

How long should I stay off my feet?

How much walking or other activities should I be doing?

What pain medication should I take?

Will ice or heat help?

If considering surgery, what are my surgical options?

You're likely to start by seeing your family health care professional. You might be referred to a specialist in physical medicine and rehabilitation, orthopedic surgery, neurology, or neurosurgery.

What you can do

Before your appointment, be prepared to answer the following questions:

When did your symptoms start?

Were you lifting, pushing or pulling anything at the time you first felt symptoms? Were you twisting your back?

Has the pain kept you from taking part in activities?

What, if anything, seems to improve your symptoms?

What, if anything, appears to worsen your symptoms?

What medicines or supplements do you take?

Feel free to ask other questions.

What to expect from your doctor

Your health care team might ask other questions, including:

Does your pain travel into your arms or legs?

Do you feel weakness or numbness in your arms or legs?

Have you noticed changes in your bowel or bladder habits?

Does coughing or sneezing worsen your pain?

Is the pain interfering with sleep or work?

Does your work involve heavy lifting?

Do you smoke or use other tobacco products?

How has your weight changed recently?

Be ready to answer questions so that you have time to talk about what's most important to you.

One Final Note..

Having a herniated disc can make you reluctant to move. But don’t just head to bed — too little movement can make pain worse when you get up again because muscles stiffen. Try to stay active and follow your healthcare provider’s recommendations for stretching. Gentle movement coupled with an over-the-counter pain reliever helps most people feel better in a few weeks.

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