First, let's talk about what a disc herniation is and what it really means. To understand this, we need to look at the anatomy of the lower back. And, remember: The spine is the backbone of support for your entire body. The spine is made up of separate, joined bones called vertebrae. In between each vertebrae is a somewhat squishy disc that is designed to provide support, mobility, and cushioning for the lower back.
The discs themselves are quite tough as they provide a lot of support while also providing mobility. However, over time and with injuries, they can develop little cracks or fissures, and they can start to leak. Leak?. . . What are they leaking? Well, inside of the disc is a jelly-like substance. When that substance escapes from out of the disc, it can start to push against the nerves—specifically, the nerves that travel from and out of the spine and down the leg. From there, those nerves go to sensory and motor nerves that control your muscles. They also go through a section of the spine that is quite narrow, so when a disc herniates and leaks that jelly-like substance onto that nerve or near that nerve, it can produce enormous amounts of pain and even weakness or drop foot (where you cannot lift your foot). Additionally, it can interfere with your sense of balance, can reduce your reaction speed, and can increases your fall risk.
On top of being incredibly painful, there are additional effects that can adversely impact your quality of life as a result of having a herniated disc. The pain is what gets the most attention because it is the leading instigator that sends people to the doctor saying, "hey, my back hurts" or "this pain is running down the back of my leg. . . I can feel it down into my calf and, sometimes, even down all the way into the foot." Unfortunately, the pain typically gets worse. Whenever you lean forward, or when you lean to the side, or when you cough or sneeze, it can be very painful because it increases the pressure on the herniated disc. As mentioned above, when you increase the pressure on the disc, it pushes out more of that jelly substance, irritating the nerves around it and sending those pain sensations throughout the length of that nerve.
The technical term here is "disc herniation" because the insides of the disc has herniated or come outwards to the outside of the disc. This type of herniation is not the more commonly known herniation that happens in the abdomen, such as an umbilical herniation or an inguinal herniation where some of the intestines have actually pushed out into the outer wall of the abdominal muscles or through the muscles of the groin. A disc herniation refers to the insides of the spinal disc going to the outside of the disc, but it is still very much contained in the body. You cannot feel this type of herniation from the outside because it is very deep.
The previously mentioned motions will bother a disc herniation quite a bit:
leaning
lifting
coughing
sneezing
This type of injury can be sneaky because it may start gradually with just a little bit of lower back pain; then, one small motion can onset a much more noticeable and painful problem. Disc herniations often start with little cracks, little injuries, or little fissures to the outside edge of the disc that steadily allow that disc to bulge, causing the insides of the disc to herniate through.
You may be wondering, what do most of us do when something like this happens? We usually go to the doctor. There is typically a lot of pain in the lower back—pain running down the leg, or maybe even weakness that results in stumbling, or perhaps even having difficulty sitting for extended periods of time. The doctor will most likely say, "This looks like it may be a disc issue. Let's get an MRI." The MRI will show them how big the disc herniation is. Whether it is big or small, your doctor will most likely say you need. . . *drum roll please*. . . SURGERY. From there, you are referred to a surgeon who reviews your MRI results, and who then agrees that you have a painful issue requiring this form of intervention. What I just gave you was the typical progression of care with this type of injury. However, there are more factors to be aware of.
The rate of spinal surgery in the United States is the highest in the world. Approximately 5x that of England, Scotland, and other developed countries. That is a direct statistic from a research article published in the Global Spine Journal. The title of the study is "Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Non-Operative Treatment." The focus being: Do large disc herniations always require surgery?
Clearly, something is going on in the United States. We have a 5 times higher rate of spine surgery than everyone else. Why is that? Here is a quote by the surgeons on what they found from this study:
"Some surgeons use the size of a lumbar disc herniation to determine whether or not a patient will ultimately fail non-operative management and require surgery. Perhaps this practice is the result of an underlying belief that spontaneous resolution of large herniations is rare and will ultimately require surgical intervention. Regardless, the literature is controversial at best in its support of utilizing disc size to inform surgical management of lumbar disc herniations. Unless patients are suffering from exigent conditions, such as cauda, equina syndrome, or a profound or progressive neurological deficit necessitating immediate surgery, most patients’ symptoms resolve without significant intervention."
A more simplified version of that statement is as follows: Despite what doctors might think, it does not matter how big the disc herniation is. Many times, there is not any evidence to suggest that a large disc herniation always needs surgery. Unless you are experiencing an actual emergency like loss of bowel or bladder control or severe weakness, most of those symptoms will resolve without surgical intervention.
As a matter of fact, these doctors go on to say that even massive disc herniations can be successfully treated conservatively. This means that patients without those red flags of the loss of bowel or bladder controller or the major weakness should always undergo 6 weeks of non-operative management before surgery is even considered. Over 90% of lumbar disc herniations will resolve on their own—especially if it is coupled with good, conservative care. What do we mean by conservative care? That means non-surgical care such as. . .
physical therapy
chiropractic
laser therapy
These Harvard doctors go on to say that, in their study, only 8.7% of the patients analyzed actually required surgery. That included even enormous disc herniations, some of which were so big they almost completely filled the area where the nerve goes through. That is amazing! We are talking just 6 weeks of conservative care that can make all the difference between having invasive surgery which carries risks, side effects, and potentially ongoing problems afterward and non-invasive care without those risks and adverse consequences. All lumbar-disc-herniation patients should pursue 6 weeks of some form of conservative care before considering surgery.
In LTI's founding clinic, there have been multiple patients with lumbar disc herniation over the years. A few of these patients had significant, large herniations, for which they had received MRIs that were sent to a surgeon. The surgeon agreed that they needed surgery and that they probably needed a fusion of the spine. A fusion is where surgeons remove the unhealthy tissue and use permanent hardware to prevent that section of the spine from even moving. These patients were very hesitant to undergo that, especially due to the fact that they were fairly young and healthy otherwise (one was around 35 years old and the other was around 55 years old). Besides the one disc herniation, the rest of the spine on both of these patients looked good. Because of this, jumping right into a fusion-type surgery was something they both realized was probably not the best option for their situation. Neither one of them were in the emergency category where they had a loss of bowel or bladder function, but they both had some weakness in the effected leg and were in significant amounts of pain. Both patients underwent a six-week, conservative care plan that included exercise, chiropractic, and laser therapy. Each of them had rapid improvements within a week! They were feeling better and have continued to get better since. They are no longer considering surgery. In fact, they are rapidly regaining strength and increasing their ability to participate in the activities they have been wanting to engage in but haven't because of their pain. All this improvement without any downtime, surgical risks, or medications.
If you or someone you know has just discovered a lumbar disc problem, are in a lot of pain, and will be going straight into surgery—stop! It may be worth a trial of conservative care, whether that is physical therapy, chiropractic, or even massage therapy coupled with exercises. Laser therapy has been shown, in many cases, to be very helpful with and resolving low back pain and disc injuries. In some cases, it even helps to repair the disc itself!
If you are saying, "but doc, what about my really big disc herniation?" Well, the researchers say that there is no correlation between the size of a disc herniation and the likelihood that a patient will require surgery after they have had their 6 weeks of non-operative management. The vast majority of patients experienced a resolution of their symptoms with conservative management and non-operative care. Additionally, while we all want to feel better as quickly as possible, these doctors say that "this should be a reminder for clinicians and patients to exhibit patience in the treatment of lumbar disc herniations." This cannot be done overnight. Even if you have surgery, there are many times where people are left with ongoing pain. Every time there is a surgical process, there is a risk of having ongoing problems with arthritis and degenerative changes.
If you are experiencing symptoms like the ones we have described above, or if you have already been diagnosed with a herniated disc, we recommend you first look for an LTI clinic near you to see if laser therapy can help resolve that condition before you seek surgical interventions.