Overview
Herniated disk is the tearing of the outer ring of the cushion (disk) between two vertebrae of the spine and the protrusion of its contents, compressing the nerve root. 1-2 million people are diagnosed with herniated disk each year in our country; it affects 1-3% of adults.
It is most common in the lumbar (L4-L5, L5-S1) and cervical (C5-C6, C6-C7) regions. Most cases improve with conservative treatment.
Symptoms
Vary depending on the location of the herniation.
Lumbar herniated disk:
- Lower back pain
- Pain radiating to the leg (sciatica):
- Starts from the hip
- Goes through the back of the thigh
- Extends to the leg, foot
- Numbness, tingling in the leg
- Weakness in the leg or foot
- Difficulty lifting the toe
- Pain worsened by coughing, sneezing
- Pain worsened by sitting, lessened by standing or lying down (usually)
Cervical herniated disk:
- Neck pain
- Pain radiating to the arm, hand
- Numbness, tingling in the arm
- Decreased hand grip strength
- Shoulder pain
- Headache
Severe, emergency conditions (Cauda Equina syndrome):
- Loss of bladder or bowel control
- Numbness in the genital area (saddle anesthesia)
- Weakness in both legs
- Severe, progressive weakness
- Requires emergency surgery!
Causes
- Age-related degeneration (most common)
- Disk water content decreases, loses elasticity
- Sudden excessive loading
- Improper lifting technique
- Trauma, accident
- Repetitive strains
- Genetic predisposition
Risk Factors
- Age: Most common between 30-50
- Being male (2 times)
- Excess weight
- Heavy lifting
- Repetitive movements (bending, twisting)
- Long sitting (especially desk work)
- Smoking (impairs disk nutrition)
- High-risk occupations (construction, healthcare)
- Family history
- Inactivity, weak back/abdominal muscles
- Poor sitting habits
Complications
- Chronic pain
- Nerve damage (numbness, weakness may be permanent)
- Cauda Equina syndrome (emergency!)
- Urinary/fecal incontinence (emergency!)
- Occupational losses
- Decreased quality of life
- Depression
When to See a Doctor
Emergency / hospital:
- Loss of bladder or bowel control
- Numbness in the genital area
- Weakness in both legs
- Rapidly progressive weakness
- Fever + back pain
- After severe trauma
Scheduled:
- Pain lasting more than 6 weeks
- Pain radiating to the leg
- Numbness, tingling
- Mild weakness
- Pain not improving with rest
- Pain waking from sleep at night
- New-onset pain over age 50
- Unexplained weight loss
Diagnosis and Treatment
Diagnosis:
- Physical examination (straight leg raise test, reflexes, strength tests)
- MRI (gold standard)
- CT (if MRI not suitable)
- X-ray (bone pathologies)
- EMG (nerve conduction study)
- Myelography (rare)
Treatment:
85-90% of cases improve without surgery.
1. Conservative treatment (first 6-12 weeks):
Rest and activity:
- Short bed rest (1-2 days)
- Then gradual activity
- Long bed rest is harmful
Medications:
- NSAIDs (ibuprofen, naproxen, diclofenac)
- Paracetamol
- Muscle relaxants (short-term)
- Neuropathic pain relievers (gabapentin, pregabalin)
- Antidepressants (duloxetine - for neuropathic pain)
- Corticosteroid (oral, short-term)
Physical therapy:
- Exercise program (core strengthening, stretching)
- Manual therapy
- Ultrasound, TENS
- Hot/cold application
- Posture training
- McKenzie exercises
Other:
- Acupuncture
- Massage
- Brace (short-term)
2. Injections:
- Epidural steroid injection: Around the nerve root
- Facet joint injection
- Selective nerve root block
3. Surgery:
Indications:
- No response to 6-12 weeks of conservative treatment
- Progressive neurological loss
- Cauda Equina syndrome (emergency)
- Severe, unbearable pain
- Athlete, occupational requirement
Methods:
- Microdiscectomy: Most common, removal of herniation through a small incision
- Endoscopic discectomy
- Laser disk decompression
- Disk prosthesis
- Spinal fusion (spine stabilization)
- Laminectomy
Prevention and Lifestyle
Proper posture:
- When sitting: feet on the floor, back straight
- Standing: weight distributed evenly
- Ergonomic chair, desk
- Computer screen at eye level
- Raise phone screen up (for the neck)
Proper lifting:
- Bend your knees (not your waist)
- Keep the load close to your body
- Do not twist suddenly
- Ask for help over 25 kg
- Use leg muscles instead of back muscles
Exercise:
- Regular exercise (150 min per week)
- Core strengthening (abdominal, back)
- Flexibility exercises (yoga, pilates)
- Swimming (joint-friendly)
- Walking
- Avoid excessive high-impact sports
Lifestyle:
- Maintain a healthy weight
- Quit smoking (for disk nutrition)
- Healthy nutrition (calcium, vitamin D)
- Do not stay in the same position for long (move every hour)
- Good quality mattress (medium firm)
- Side sleeping (pillow between knees)
- Manage stress (relaxes muscles)
- Adequate sleep
- Proper footwear (cushioned heel)