Herniated disc

A herniated disc (or prolapsed disc) is a bulge in the back wall of a disc or a squeezing out of its contents that persists even when there is no pressure.

It is necessary to explain the causes of this disease, because for many years it was believed that all back problems were caused by a herniated disc. In the 1930s, discs were declared the main cause of back pain, and this concept has prevailed almost to this day.

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How does a herniated disc occur?

When something unexpected happens to the back, it is assumed that a disc has shifted relative to the general line of the spine - like a saucer jumping out of a shot glass - and pinched a nearby nerve. When the pain is mild and generalized, the diagnosis may be destruction or complete depletion of the disc (osteochondrosis). (Arthritis of the facet joints has only recently come to the fore.)

The fibrous ring does sometimes bulge, but according to modern research, this is only the cause of back problems in 5% of cases. A true herniated disc is characterized by the ring bulging in one place when the nucleus has degenerated, disintegrated, and been squeezed out of the center in the process of general destruction. The pain comes not so much from the disc (the disc is like a fingernail, with almost no nerves) as from the pain-sensitive structures affected by the herniation.

When a disc loses its properties, a herniated disc can form in the area where the back wall resists the load.

If a disc herniates at the back of the annulus fibrosus, it can cause compression of the cauda equina, causing symptoms such as deep back pain, impotence, bowel and excretory problems, and sciatic numbness. If the disc bulges posterolaterally, it can cause compression of the spinal nerves, causing pain down the leg, numbness, tingling, and general muscle weakness in the calf or foot.

A herniated disc does not occur suddenly - it is always a natural result of certain changes in the disc. A herniated disc is only part of the overall picture, and the disc wall is destroyed over a long period of time. This simply cannot happen while the segment is healthy. (Laboratory studies have shown that with increasing load, the bone is destroyed much faster than the disc.)

A single awkward movement will never dislodge a disc, turning a person into a cripple. When healthy, discs are amazingly strong, and cannot be dislodged by a poorly calculated movement. They are unusually flexible connecting links between the vertebrae.

Sometimes the facet joint may dislocate slightly, but the wall of the disc simply bulges (called a protrusion), and in some cases the prolapse ruptures, releasing its contents - the abnormal nucleus - into the spinal column, where it either drifts or wraps around a nerve root, forming a sequestrum. This sounds horrific, but in reality the nucleus material is eventually absorbed into the blood, although if it has degenerated the body may respond with an autoimmune reaction that irritates the nerve roots.

Perhaps the expressiveness of the word "prolapse", which was often used as a synonym for a herniated, damaged wall of the disc, so captured the imagination of both patients and specialists that it led to some congestion in the attitude towards this problem. When you have severe back pain, the word itself evokes bad associations, as if something had fallen out and blocked the entire system, although the mechanism of the spine is too complex for something so primitive to happen. It is simply amazing how many "sins" were attributed to such an unlikely cause, and as a result, this rare disease has acquired the widest notoriety.

In fact, herniated discs are common, but they are extremely rare causes of human suffering. This has only recently been proven with the advent of magnetic resonance imaging. Extensive studies were conducted among those who did not have back pain (without the risk of radiation, which is inevitable with X-ray myelography) to see what the most ordinary back looks like from the inside. To everyone's amazement, it turned out that every fifth person under 60 had a herniated disc, and people did not even suspect anything. Among older people, the figure was no less impressive: the disc was damaged in every third person, also without any symptoms. Almost 80% of the subjects were found to have a herniated disc. It became completely obvious that a herniated disc is not the main source of trouble, as was always believed.

A herniated disc occurs when other disorders in the motion segment cause muscle spasm. The structures around the disc are very sensitive to pain, and if they become inflamed, they can easily turn on the muscular defense. When the defense reaction continues for too long, the segment is compressed, and the disc wall eventually deforms. Tonic vertical compression of the muscles, especially at the problematic level, gradually squeezes out the fluid from the disc, and the swelling in it begins to play its fatal role.

With healthy discs, this never happens. They expand briefly by a few millimeters to take on the load, but this is not at all like a pinched segment, when the fibrous ring deforms at a weak point. Healthy discs are extremely elastic and never suddenly deform or rupture. Stories about how a disc slipped during an awkward movement and a sudden pain appeared down the leg are not stories about a herniated disc. There was always an initial disorder, even if it was unnoticeable and did not cause any symptoms. Sciatica caused by changes in the disc usually "matures" for several years, initially manifesting itself as a disturbing pain in the lower back, as if the mobility of a spinal segment was limited. Eventually, everything moves from the dead point, and the initial pain is replaced by a new one, radiating into the leg.

What causes a herniated disc?

• Long-term disorder qualitatively changes the nucleus and weakens the disc wall.
• The disc wall ruptures due to bending of the back and lifting heavy objects.

Long-term disorder qualitatively changes the nucleus and weakens the disc wall

The discs are designed to absorb shock, so they need to be voluminous. In a healthy state, the thickness of each disc increases imperceptibly as we shift our weight from one foot to the other during normal daily activities. As pressure passes down the spine, the core distributes the load in all directions. Thanks to the hydraulic bag effect, compression is converted into a springy, pushing force, which gives the connecting links of the spine their elasticity and protects the entire spinal column from vibration when we step on the ground.

When the spine bends and straightens during movement, a synchronous exchange of energy occurs. First, the core is deformed, and a moment later, the fibers of the disc wall are stretched as it takes on the load. When the wall has stretched almost to its limit, it gently pushes the “energy” back to the core, causing it to swell. Thanks to this magnificent dynamics, the disc absorbs shocks, and our gait becomes springy.

Energy exchange works well when both the nucleus and the annulus are healthy. As long as the nucleus retains its normal consistency and the annulus its elasticity, the disc can absorb pressure indefinitely. But damage to either the facet joint or the disc – or too much muscle spasm – can change everything. Limited mobility in the anterior segment and arthritis of the facet joint at the back can eventually cause the disc to herniate, destroying its viability.

Often it all starts with a muscle spasm; even a minor disorder can become chronic if the protective reaction of the muscles does not pass. The segment is as if clamped in a vice, which makes the dynamics of energy exchange difficult. When muscle spasm and tightness persist, the disc begins to bulge around the entire circumference. This is still a minor and easily correctable flattening, but over time the disc can fail.

As the disc becomes dehydrated, the nucleus becomes more viscous and prone to deformation. It no longer resembles a tight ball with liquid inside, it deforms and flows under pressure. When the nucleus is squeezed in different directions by the movements of the spine, it runs into the inner layers of the fibrous ring - and this is the only thing that limits it. Over time, constant impacts traumatize the wall of the disc, and it begins to collapse.

Actions that increase pressure inside the disc only accelerate its destruction. For example, when bending, which is almost always accompanied by rotational movements, the load falls on the back of the fibrous ring.

The disc wall ruptures due to bending of the back and lifting heavy objects.

When the body is strained by lifting heavy objects, multiple fiber tears in one area of the annulus fibrosus can develop into a small crack into which the nucleus is forced.

When the nucleus moves, frequent back bending can have the most serious consequences. The pressure inside the disc increases when bending. If the bending is accompanied by rotation (even a slight one), the pressure increases even more, because the muscular effort compresses the disc. When the rotation occurs all the time in the same direction, the nucleus destroys the same section of the fibrous ring layer by layer until it breaks.

The last straw may be the effort of lifting weights. It subjects the spine, and especially the lower discs, to enormous strain. The pressure inside the disc becomes simply incredible, more and more fibers tear in the same place, and eventually the wall breaks through from the inside. Gradually, the nucleus is squeezed into the resulting crack and widens it on its way out. As a result, the entire wall may rupture, and the nucleus will fall into the spinal canal, forming a herniated disc.

Additional risk factors for herniated disc

A rupture of the disc wall will occur more quickly if the lifted load is held away from the body or if it is something very heavy. In both cases, the pressure inside the disc increases. A rupture is also easily caused by twisting the body. When the segment is displaced forward, the facet joints move apart, making the disc more vulnerable; alternating layers of the wall tend to separate, causing peripheral tears in the outer layers. With an obvious internal malfunction in kidney-shaped discs, at the points of greatest curvature, the rupture may meet the peripheral one, and the nucleus will be squeezed through different parts of the wall.

The combination of the pressure of the core from the inside and the external tension of the wall during rotation results in the disc most often rupturing at the points that, if you compare it to a clock face, roughly correspond to 5 and 7 o'clock. This explains why posterolateral disc herniations predominate. Posterolateral disc herniations most often occur on the right (rather than the left), which may be due to the fact that there are more right-handed people. The muscles of the right side of the body and the right arm put additional pressure on the disc.

Here's a great example of Murphy's Law: These areas of greatest disc rounding are where the sciatic nerve roots exit the spinal canal. They travel down the canal in multiple strands and then exit at the appropriate level through the intervertebral foramina. A posterior disc bulge can compress a nerve root inside the spinal canal, and a posterolateral disc bulge can irritate a nerve in the intervertebral foramen. There's much less room in the foramen than in the spinal canal, so the nerve suffers doubly. It can be simultaneously pressed against the back wall and stretched along the contour of the bulge (much like when we have to squeeze past a fat lady on a bus to get to the exit).

Not surprisingly, herniated discs are often caused by heavy physical work. The worst type is lifting heavy objects that involve twisting the body: for example, digging with a long-handled shovel or constantly bending over to lift boxes from the same height to the floor. Nurses often suffer from back problems, although these problems are not always related to the discs. Unsuccessful lifting can weaken the wall of the disc, but for the nucleus to be squeezed out, the disc must already be damaged.

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What's going on with your back?

Acute herniated disc

A few days after a spinal injury, pain gradually appears in the leg. Usually, a person can remember exactly what he or she was doing when the pain occurred, but very rarely was the back involved. Perhaps it was slightly tense, and there was a sharp pain in it that quickly passed. Perhaps you injured the spine by unsuccessfully lifting something that was not the heaviest, but very uncomfortable. Perhaps you were dragging a sofa by one armrest, and its corner got caught on something. Your struggle with the sofa may be the last straw, and an acute tension will appear in the back. For the next few days, the back remains sore and tense, and then the pain begins to radiate to the leg.

The painful tension is felt deep in the buttock and radiates down the leg, then develops into an unbearable cramping pain. At first it feels like a muscle or ligament is simply pulled in the leg. The pain usually starts in the buttock and goes down to the thigh, then, skipping the knee, returns to the calf. If you probe deeply into the buttocks with your fingertips, you can find the source of the pain, and, oddly enough, pressing on this point soothes the pain in the leg.

The nerve may become inflamed and so sensitive to tension that you cannot even lower your heel to the floor. The spine is usually forced to bend to the side (this is scoliosis in sciatic neuralgia) to relieve tension on the nerve root. From behind, the spine appears completely twisted and weak. Sometimes not only is there a lateral curvature, but a hump appears in the lumbar region instead of a hollow. The buttock on the affected side may become flat and flabby. Both spinal deformities are protective mechanisms that minimize tension on the inflamed nerve root.

When you stand, you lean on the toes of the affected leg and bend it at the knee so as not to stretch the nerve; the leg often trembles uncontrollably. When you walk, you limp miserably. Each step causes a terrible, almost unconscious pain in the leg, as if a sharp, red-hot spear were being stuck into it (usually described as a shooting pain in the leg). Bending forward is almost impossible. When you try to bend over, a severe pain arises in the leg, and the spine bends even more, as if from the wind, to avoid stretching.

With an acute disc herniation, you look terrible: when you stand, you can't put your heel on the floor, and walking becomes a helpless hobble because you can't stretch the nerve to move your leg forward.

Sitting is usually simply impossible, as the compression of the spine increases the pressure on the disc, and therefore on the nerve. After just a few seconds of sitting, the pain can become so severe that you have to stand up and lean on something to free your leg. The pain can be just as unbearable after a few minutes of standing, when the pressure on the disc gradually increases the cramping pain. The most comfortable position is lying on your side in the fetal position with a pillow between your knees.

What causes acute pain from a herniated disc?

It is possible that the back pain that occurs in a condition such as an acute herniated disc is caused by a stretching of the disc wall. Pressure on the local protrusion stimulates the mechanoreceptors between the fibers, which manifests itself in deep back pain that is not relieved by manual application to the sore spot.

The disc itself is almost insensitive to pain. Only the outer layers of its wall are innervated, and this explains why minor protrusions are painless. The inner layers of the fibrous ring withstand the main pressure of the nucleus shifting to the side and protect the sensitive outer layers from direct contact with it.

The destroyed nucleus moves and, like a wedge, penetrates small cracks in the inner layers of the wall and widens them as it moves outward. When only a few layers remain to restrain it, the tension in the disc wall is at its maximum, and is further increased by muscle spasm. (This may explain why a problematic disc often explodes with a loud bang when the surgeon's scalpel cuts through it, sending the nucleus flying several meters across the operating room.)

As your condition worsens, the nerve tension causes more pain than the compression, the usual back pain disappears, but leg pain appears. This may be due to the nucleus spontaneously breaking through the outer wall. This relieves the pressure on the wall, but new problems arise. At this point, the nucleus may have acquired a brownish tint (meaning it has degenerated and become toxic), and is now chemically irritating the nerve root.

It is believed that the tension of a nerve root is more disturbing than its compression. We have all had to lean on the condyle of the humerus at the elbow, and we know that nerves tolerate pressure quite well. They may temporarily lose conductivity, and the arm will go numb; this is unpleasant, and when the arm begins to move away, it will run goosebumps, but it does not cause severe pain. By pulling the nerve tightly, and therefore subjecting it not only to stretching but also to friction, we irritate it much more. Therefore, a small bulge in which the nerve is not stretched will be painless.

The first thing that happens to a nerve when it is compressed (and stretched) is that its blood circulation is disrupted. Fresh blood cannot reach the affected area, and the blocked, stagnant blood cannot remove metabolic waste products. Both irritate the free nerve endings in the surrounding tissues, and you feel increasing discomfort in the problem area.

Remember that the inflammatory reaction is not specific to the disc because it is deprived of blood supply. It occurs in other tissues around the disc, which become red, swollen and thus increase the overall compression. The muscle spasm around the segment is intensified because of this, the pressure increases, and everything swells even more - including the disc. In a limited space, all structures become even more inflamed and come into even closer contact with each other.

When a nerve is both compressed and stretched, friction occurs between the taut nerve and its own protective sheath. The physical friction of the two hyperemic (blood-filled) surfaces causes increasingly severe pain as the nerve becomes more inflamed. A clear fluid, similar to that seen in a burn, oozes from the damaged and inflamed surfaces, and the pain becomes unbearable.

If you were to look inside, you would see an incredibly red and swollen nerve, with tissues drowning in fluid around it. It is this metabolic state that causes excruciating leg pain; it is very difficult to treat conservatively.

The disc, as the least blood-supplied part of the segment, is indeed the best object for surgical removal when the process has gone so far. If everything is blocked by irreversible congestive edema, it is the disc, a highly compressed but inert component, that is easiest to separate and cut out. This is the quickest and most effective way to relieve the tension from the segment when all conservative methods have failed, regardless of the adverse effects it may have on the entire spine in the future.

Chronic intervertebral disc herniation

By this time, the bulge is no longer very noticeable, although the disc still causes you pain. In the chronic phase, the internal structures of the segment fight residual inflammation, and pain can occur for several reasons. For example, there may be symptoms of chronic limitation of mobility of the spinal segment and arthropathy of the facet joints, as well as chronic fibrosis of the once inflamed nerve root. As a consequence of the previous acute inflammation, the fluid oozing from the nerve gradually hardens, forming scar tissue. This mass glues the nerve to its sheath and to other nearby structures, including the walls of the intervertebral foramen. The entire segment is permeated with dry whitish scars, creating a kind of collar that gradually compresses the nerve. This is the so-called fibrosis of the nerve root sheath.

Such a collar fixes the nerve and does not allow it to pass freely through the bone opening when the leg moves. A dense network of adhesions dictates its own laws, the nerve is often attached to the back of the disc. From prolonged compression, it becomes significantly thinner. The leg seems to be an extension of the back. It is impossible to bend it freely at the hip either to sit down or to step forward, the back moves with it all the time - this is why you have a characteristic limp. The back is compressed, all actions are accompanied by various pains, pain in the leg appears and disappears, depending on the degree of tension of the nerve.

Sometimes the spinal cord becomes attached to the inner wall of the canal by scar tissue. When you sit, your back cannot bend and there is a feeling of tension in your back that extends up your spine and down into your buttock and thigh. This is called tethering. When you sit, the spinal cord stretches and tries to break the adhesion, causing a deep, breath-taking pain that can extend all the way to your shoulder blades. Sometimes you can almost feel the tension in your spine from the inside when you bend over.

If only the nerve root is fixed in the intervertebral foramen, most of the symptoms will be in the leg. When sitting, the buttocks tend to move forward to reduce the angle at which the hips are raised; when trying to straighten the leg, the knee automatically bends. Over time, other symptoms may develop when sitting, such as numbness in the heel or pain in the foot. But the worst is a dull, aching pain in the hip, because bending the back stretches the nerve root where it attaches to the intervertebral foramen. And long after all other symptoms have disappeared, a long car ride or plane ride can cause pain that you haven’t felt in years.

In addition to a weak leg and difficulty sitting, there are more subtle signs of nerve damage. The muscles on the affected side may be slightly wasted. The buttock may become flat and flabby, as may the calf, where muscle tone is reduced. Signs may be less obvious, such as a flattening of the arch of the foot, causing the forefoot to widen and make it feel like your foot is too big for your shoe. You may notice that you have difficulty doing certain things, such as standing on your toes or pushing something off with your affected foot. When walking, your feet may feel too heavy, harder to control, and you may have to pull them up to take a step.

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What causes chronic pain from a herniated disc?

A sudden stretch on a nerve, such as from being kicked with a soccer ball, can cause a local inflammatory reaction where the nerve is attached to the foramen. The nerve cannot be torn away, like boiled spaghetti stuck to a pot, it can barely move. The sudden movement can damage a few adhesions and cause a small bleed in the scar tissue, and then more scar tissue will form at the site, making the situation worse. At this point, the familiar leg pain becomes more severe because the nerve is irritated by the local inflammatory reaction.

Active growth of adhesions can eventually lead to narrowing of the spinal canal, since the nerve's own blood supply is hampered by the overgrowth of the intervertebral foramen. In this condition, the legs always hurt, with any movement. After walking even a short distance, you are forced to sit down and rest, it is especially difficult to climb uphill or up stairs.

Normally, when the leg muscles are actively working as a pump, moving the body, the nerve sucks in blood and thanks to this maintains its ability to transmit impulses to the brain. When everything is convulsively compressed, the nerve cannot absorb blood. It suffers from a lack of oxygen, and the legs become heavier and heavier until the most severe cramping pain blocks them completely - then you have to stop. You need to rest - bend over or squat, which expands the diameter of the spinal canal, passing more blood, and therefore brings relief. Narrowing of the spinal canal can also be observed in arthropathy of the facet joint: swelling of the joint affects the nerve in much the same way.

After a few minutes, the pain subsides and you feel better. However, when you resume walking, you will feel the pain sooner and have to stop to rest sooner than before. Each time, you will walk shorter distances before your legs become painful and heavy, forcing you to stop. At the end of the walk, you will have to stop just as you begin to walk. (It is the shorter time between stops that distinguishes the pain of spinal stenosis from the cramping pain caused by circulatory problems.)

Although there are obvious organic reasons for your legs to fail, it is amazing how much their condition changes from day to day. One day you can walk a block, and the next you can barely make it to the sidewalk. The variable in this equation is the spasm of your back muscles. Even with minimal spasm, the segment is more compressed, making it even harder for blood to flow through it. Anxiety and psychological stress also play a role, because they directly affect muscle tone. When you are very tired or nervous, your legs move less, and the familiar feeling of walking in thick molasses occurs over the shortest distances. Other days, seemingly out of nowhere, you literally float.

How is a herniated disc recognized?

Discs have always been difficult to say anything definitively about because they are hard to see. The disc material is transparent to X-rays, so it is impossible to get a clear picture of it on an X-ray. To find out whether a herniated disc was affecting the spinal cord (through the spinal canal) or pinching a spinal nerve (in the intervertebral foramen), a contrast agent was injected into the spinal canal; the patient then leaned over to let the dye flow around the disc. An X-ray was then taken to show its outline. The entire procedure is called a myelogram.

Fortunately, this very unpleasant procedure (after which the patient often suffered from headaches for several days, and in more serious cases he could develop arachnoiditis - inflammation of the membrane of the spinal cord) was completely replaced first by X-ray computed tomography and then by magnetic resonance imaging. Although the latter is expensive, it gives very clear, almost three-dimensional images of both soft tissue and bone, clarifying the situation in all vertebral structures.

The physical therapist cannot palpate the discs with his hands because they are located in the anterior complex of the spine. He can only ascertain the general condition of the spinal column by palpating it through the spinous processes. Although palpation may reveal a characteristic "ligament" of the spine when the disc is strongly protruding, this is very difficult to detect. Sometimes light pressure with the hands irritates the disc and causes pain in a distant part of the body, perhaps because its deformed wall affects a nerve root. If minimal pressure causes cramping pain in the leg, this indicates that the nerve is very irritated, although it is necessary to exclude arthropathy of the facet joint. To do this, palpate the back 1-2 cm to the side of the central groove.

Since the disc itself cannot be palpated, one has to rely on objective symptoms indicating that a nerve root is compressed. These are the so-called neurological symptoms of a herniated disc, they indicate how much the nerve is irritated and how much it has lost its function. One of the tests is to raise a straight leg at an angle of 90 degrees. By increasing the tension of the nerve roots, you can find out whether one of them is inflamed. When a nerve is inflamed, a sharp pain appears as soon as you lift your leg off the bed. Other neurological symptoms are decreased or complete absence of reflexes (in the ankle and under the knee), numbness of the skin on the leg and loss of muscle strength. However, almost the same symptoms are characteristic of acute inflammation of the facet joints. It seems to me that one can conclude that this is a herniated disc if there are also disorders in the functioning of the intestines and bladder (which cannot be caused by the facet joint).

You can be absolutely sure that it is a herniated disc only when everything is fine with the facet joints. Too often, patients come to the clinic with the verdict: "disc surgery is indicated", while all the symptoms point to a pinched nerve. As a result, the most superficial manual work on the facet joint at the same level relieves it of the problem in a few days.

A herniated disc is very difficult to treat conservatively, but it is possible. Once the nucleus has shifted, it is very difficult to put it back; it is like putting toothpaste back into the tube. The only trick is to mobilize the entire segment to relieve the compression. Relaxation takes the pressure off the disc and allows it to hold more fluid, and improves blood circulation to the entire area, which means it relieves inflammation caused by swelling of the structures within the segment (the disc is just one of them).

Even when a herniated disc is diagnosed with a CT or MRI scan, it is very treatable. If the damaged segment can be made to move normally along with the entire spine, even the most severe leg pain can be eliminated. However, after severe inflammation, the nerve root will remain hypersensitive and vulnerable for many months or even years, especially after sitting for a long time. Even with a mild muscle spasm or circulatory problems, the familiar leg pain can return.

What to do if you have a herniated disc?

In the acute phase, the most important thing is to open the back of the lumbar vertebrae to relieve pressure from the protrusion. This can be achieved by pulling your knees to your chest, but the improvement will be short-lived unless the muscle spasm is relieved. And this will not happen until the inflammation of the soft tissues is cured. In any case, you need to take the medications prescribed by your doctor (non-steroidal anti-inflammatory drugs and muscle relaxants). Pulling your knees to your chin will also help relieve muscle spasm, even with acute sciatica.

Once the swelling has gone down and the nerve inflammation has subsided, it is important to achieve separation of the segments. This is where back block exercises and squatting are important, causing fluid to flow into the discs. At the same time, strenuous forward bends from a lying position increase intra-abdominal pressure, which also relieves the strain on the discs.

Chronic intervertebral disc herniation should be treated based on stabilization and stretching. Sometimes segment instability is imminent, caused by decreased pressure inside the disc and weakening of its wall. Toe-touching bends, including diagonal bends, help fluid flow into the discs and strengthen the deep muscles that connect the segments. Diagonal toe-touching bends and diagonal twisting eliminate adhesions in the intervertebral foramina that may remain from inflammation. The nerve root may be attached to other structures, and rhythmic stretching and contraction of the nerve during bends helps to gently release it. At this stage, rotational movements of the spine relax the fibers of the disc wall, allowing it to more freely absorb water.

Typical treatment for acute herniated disc

Goal: To relieve muscle spasm, open the posterior complex of the spine to relieve pressure from the damaged disc.

• Knee to Chest Pulls (60 seconds)
• Relaxation (with pillow under lower legs) (30 seconds)
• Knee to chest pull-ups
• Relaxation
• Knee to chest pull-ups
• Relaxation
• Knee to chest pull-ups
• Relaxation
• Knee to chest pull-ups
• Relaxation
• Knee to chest pull-ups
• Relaxation

Take the medications prescribed by your doctor. Lie in bed most of the time with your feet on a stool or pillows so that your thighs and shins form a right angle. Repeat pulling your knees to your chest and chin at least every half hour.

Duration: Move to the subacute regimen if the leg pain is no longer constant.

Typical treatment of intervertebral disc herniation in the subacute phase of disc herniation

Goal: relieve muscle spasm; relax the back to increase fluid flow into the disc; strengthen the abdominal muscles to relieve pressure on the disc.

• Knee to Chest Pulls (60 seconds)
• Back rolls (15-30 seconds)
• Knee to Chin Pulls (5 times)
• Squatting (30 seconds)
• Knee to chest pull-ups
• Back rolls
• Knee to Chin Pull
• Squatting
• Back Block Exercise (60 seconds)
• Knee to Chest Pulls (30 seconds)
• Knee to Chin Pulls (15 times)
• Squatting (30 seconds)

Exercises should be done early in the morning or in the afternoon, and then relax for 20 minutes, placing a pillow or stool under the lower part of your legs. When you are doing your business, avoid staying in one position for a long time; try to walk at least 2 times a day (no more than 15 minutes).

Typical Treatment for Herniated Disc in Chronic Disc Herniation

Purpose: to relieve compression of the base of the spine, stretch adhesions, restore coordination of the abdominal and back muscles.

• Squatting (30 seconds)
• Back Block Exercise (60 seconds)
• Knee to Chest Pulls (60 seconds)
• Forward bends from a lying position (15 times)
• Squatting
• Block Exercise for the Back
• Knee to chest pull-ups
• Forward bends from a lying position
• Squatting
• Diagonal twisting in a lying position (2 times on the sore side, 1 time on the healthy side)
• Squatting
• Lying Diagonal Twist
• Diagonal bends with touching toes (4 times on the sore side, 1 time on the healthy side - repeat three times)
• Squatting
• Squatting
• Block Exercise for the Back
• Knee to chest pull-ups
• Forward bends from a lying position
• Repeat the entire complex 3 times a week.

If your leg hurts when bending forward from a lying position, replace it with pulling your knees to your chin. Leg pain can occur after prolonged sitting or traveling. In this case, you need to return to the subacute phase regimen.

Surgical treatment of intervertebral disc herniation

Surgical removal of a herniated disc is usually unsuccessful because the metabolic disturbance within the inflamed segment contributes to the irritation of the nerve root. By some estimates, 50% of patients who have had surgery for a herniated disc do not improve and sometimes even worsen. Removing the disc does not always solve the problem and in many cases only makes it worse. When both the disc and the facet joint are swollen, intermittent leg pain is likely to originate from the facet joint. The rich blood supply to the facet joint makes it more susceptible.
In fact, the main source of pain is the facet joints, so removing the disc shortens the segment and forces these joints to bear more weight. After surgery, the leg pain intensifies - and this is so depressing for the patient, especially after everything he has had to endure. As soon as you get up, all the symptoms reappear in all their glory. Sometimes you hear about a repeat operation in 2-3 weeks, already at a different level.

Still, many spinal surgeries are successful. In the past, a more radical operation called a laminectomy was performed, which involved first removing the entire disc (pulling it off piece by piece with a scalpel and forceps, like ripping off a fingernail) and then removing part of the bony arch of the vertebra above and below the nerve. Sometimes, the same operation would also involve joining the spinal segments together to prevent instability from breaking down the fibrous connective tissue, either by filling the empty space where the disc had been with bone fragments (usually taken from the iliac crest) or by inserting two large bolts into the facet joints. More recently, spinal surgery has become less radical (and less disruptive to the mechanics of the spine when it is forced to move again).

Disc microectomy is a much more delicate operation: through a tiny incision in the skin, as little of the disc as possible is removed (basically just the herniated disc itself). The wound is small and there are few cuts, so the scar is almost invisible. The best surgeons not only do what is necessary, but also restore the cut thoracolumbar fascia before stitching the wound. Thanks to this, vertical fixation of the spinal segments is maintained (and this ultimately helps to avoid instability). It is also very important to minimize blood loss during the operation. Many doctors recommend that the patient return to normal motor activity as soon as possible after the removal of the herniated disc. Movement prevents stagnation of blood and lymph in the tissues, so fewer adhesions occur, which prevent all the moving structures of the spine from starting to work again.

More selective surgeons use the strictest criteria, in which case a herniated disc is operated only when there are neurological symptoms in the sciatic region and the legs cannot function normally. Pain itself is not a reason to open up the back and remove the disc. It is too subjective a factor. In addition, pain can be caused by many other disorders. Imagine how terrible it is when the disc is removed and the pain remains - and this happens very often.