Lumbar disc herniation: treatment and surgery

What is a lumbar disc herniation?

Between the vertebrae of your back are the intervertebral discs: shock absorbers with a tough fibrous ring and a soft core. Through wear and tear or overload, this ring can tear, allowing part of the core to bulge outwards. This is called a disc herniation (or slipped disc). If this fragment presses on a nerve root, the typical symptoms appear.

Drawing of the lower back with a bulging intervertebral disc pressing on a nerve, next to a healthy disc. — In a disc herniation, the tough outer ring of the intervertebral disc tears and the soft core bulges out. This bulge can press on a nerve root. That causes the typical pain radiating into the leg. Image: InjuryMap, CC BY-SA 4.0, via Wikimedia Commons.

What symptoms does a lumbar disc herniation cause?

Pain from the back or buttock that radiates into the leg, sometimes down to the foot ("sciatica")
Tingling or numbness in the leg or foot
In more severe cases: loss of strength, for example a foot drop

Warning signs: loss of bladder or bowel control, or numbness in the saddle area (between the legs and around the buttocks). In that case, contact a doctor or an emergency department immediately.

Does a disc herniation need surgery?

Usually not. Most disc herniations heal on their own within six to twelve weeks. Initial treatment consists of pain relief, anti-inflammatories and staying active as far as the pain allows, with close follow-up by your doctor. Surgery is only proposed when symptoms persist despite this treatment, or sooner if weakness is increasing.

Side-view MRI of the lumbar spine with red circles around two bulging intervertebral discs. — Side-view MRI of the lower back. Upper red circle: a disc herniation between the fourth and fifth lumbar vertebrae (L4-L5) touching the L5 nerve root. Lower circle: a slight bulge without nerve compression. Not every bulge on an MRI causes symptoms; the decision depends on what you feel and how things develop. Image: Miguel Tremblay, CC0, via Wikimedia Commons.

Important to know beforehand: the operation is mainly effective against leg pain. It has less effect on back pain itself. Dr Lavrysen discusses this with you openly, so that you can decide with realistic expectations.

How is the operation performed?

The standard technique is the microsurgical discectomy (microdiscectomy): through a small incision in the back, the muscles are not cut but gently moved aside, after which the trapped nerve root is freed under the operating microscope and the herniation removed. In selected cases the operation can be performed endoscopically, through a working channel of less than one centimetre.

Two magnified views through a small opening between two vertebrae: the yellow nerve root is freed and checked with fine instruments. — **Microscopic discectomy (1).** Through a small opening between two vertebral arches (red line), the surgeon brings the trapped nerve root (yellow) into view under the microscope. Using fine instruments, the nerve is freed and gently held aside, so that the herniation underneath can be reached. Image: © AO Foundation, AO Surgery Reference.

Cross-section of a lumbar vertebra seen from above: the dural sac is held aside and the fibrous ring of the intervertebral disc is opened with a small blade; two insets show a slit-shaped and a window-shaped opening. — **Microscopic discectomy (2).** Cross-section seen from above. While the dural sac containing the nerve roots is held aside, the surgeon opens the fibrous ring with a small incision (slit- or window-shaped, see insets) and removes the bulging piece of the core. The rest of the disc is preserved. Image: © AO Foundation, AO Surgery Reference.

Side view of the lumbar spine: a thin instrument enters obliquely from the side through the nerve opening, just below the exiting yellow nerve root, as far as the intervertebral disc. — **Transforaminal endoscopic discectomy.** With this technique, the surgeon does not approach through the middle of the back, but obliquely from the side, through the natural opening through which the nerve leaves the spine (the foramen). Under X-ray guidance, a thin needle is guided to the disc just below the exiting nerve (yellow); a working channel of less than one centimetre with a camera is then placed over it, through which the herniation is removed. Muscles and vertebral arches remain virtually untouched. Not every herniation is suitable for this; its position on the MRI determines the choice. Image: © AO Foundation, AO Surgery Reference.

How quickly will I recover?

A few hours after the operation you are back on your feet. Walking is encouraged from day one; office work and driving are usually possible after about two weeks, physical work and sport after around six weeks, always in consultation.

What are the risks?

As with any operation: post-operative bleeding, infection, a small tear in the dura (the membrane surrounding the nerves), and rarely nerve damage. In addition, in 5 to 10% of patients a new herniation may occur at the same level over time. All risks are discussed with you before the operation.

Frequently asked questions

How long does the operation take?

On average about one hour.

Will I have a microsurgical or an endoscopic operation?

That is determined by the MRI: the position and type of the herniation. Both are minimally invasive; Dr Lavrysen will explain the choice during the consultation.

Will my back pain go away too?

The operation targets the leg pain. Back pain due to wear and tear improves less predictably. Dr Lavrysen will discuss the further options with you; these are usually non-surgical.