The spinal column is made up of 2 components: the vertebral
bodies and the intervertebral discs (shock absorbers between the bodies)
that give flexibility to the back and at the same time protect the spinal cord
and nerves.
The intervertebral disc has two
components, a soft center and
gelatinous (NUCLEUS) encapsulated in a hard and fibrotic outer ring
(FIBROUS
ANNULUS). Lumbar disc herniation is
produced when there is a rupture of the
fibrotic annulus and there is an outflow or
protrusion of the nucleus through the defect of the
annulus and the
nerve structures are compressed causing painful symptoms
in the back and legs.
Depending on the location of the herniated disc it causes back pain, pain and/or
numbness in areas of the buttock, thigh, leg or foot and weakness in
different parts of the legs, depending on the nerve affected.
The vast majority of the time the symptoms are self-limiting and tend to improve
over time. In general, herniated discs are resolved with medication,
analgesics, anti-inflammatory drugs and spinal blocks, it should be noted that in few cases surgery is required
.

Signs and symptoms depend on the level where the herniated disc is located and
which nerve is compressed. Generally, herniated discs affect one
side of the body.
● Leg pain starts in the lower back or buttock region and moves down the
leg through the thigh and calf or foot, depending on which nerve is affected
you will feel pain in different parts of the leg. This pain may
appear or increase when you cough, sneeze or in certain positions.
The pain is often described as stabbing or burning. (Illustration 2)
● Numbness or
tingling. People who
have a herniated disc
often have
numbness or tingling that radiates down
different parts of the leg in a very similar area
where the pain is distributed. (Illustration 2)
● Weakness. Each muscle group in the legs receives
information from a specific nerve in the spine and generates a particular
movement, the herniation depending on which nerve compresses
decreases the strength in the muscle group and affects a particular movement
in the leg, thus altering the gait dynamics.

You can have a herniated disc and not have any of these symptoms,

Illustration

may be diagnosed only by spinal resonance imaging, in this case no management is required
.

Seek medical attention if your back pain runs down your leg and through the
buttock, thigh, leg and/or foot, or if you also have numbness,
tingling or weakness, these symptoms may indicate that you are experiencing
a herniated lumbar disc and require diagnosis and treatment.

A herniated disc is the result of a slow, gradual wear and tear related
to the natural aging that all body tissues undergo
(disc degeneration). As they age, the discs lose their
water content, lose flexibility and this tears the annulus with
movements.
In most cases a causative event cannot be determined, but
often the onset of symptoms is reported after lifting objects or
rotating the spine while carrying the heavy object, in a few
occasions, a traumatic event such as a fall from height or
traffic accident causes the herniation.

Factors that increase the risk of developing a herniated disc are:
● Weight: Excess body weight causes additional overload and stress on
the discs in the lumbar region.
● Work: People with jobs with high physical loads (e.g.,
construction employees) due to repetitive lifting,
pulling, pushing, rotating or tilting the lateral spine or lifting objects from

more than 20kg, may increase the risk of presenting a herniated
lumbar disc.
● Genetics: there are families with a greater predisposition to have a
herniated disc.
● Smoking: Theoretically smoking decreases the supply of oxygen to
the discs.
● Undirected physical exercise : Exercise with postures and loads not
appropriate increase the risk of a herniated disc.

When herniated discs are not properly managed (according to
symptoms, clinical findings and diagnostic imaging results)
there is a risk of chronic leg pain, weakness, limitation of ambulation
and/or impaired sphincter control, these lesions are late and are
prevented with early and appropriate management as appropriate.
Consultation with the emergency department is required if the following
alarm signs or symptoms are present:
● Pain, numbness or weakness in the leg that is increasing
progressively and getting worse each day, that the pain alters the possibility
of walking or not being able to move any part of the leg.
● Inability to control bladder, incontinence or difficulty
urinating, rectal incontinence or severe constipation.
● Progressive loss of sensation in the inner thighs, the
back of the legs, the genital area, the gluteal area and the
rectal area, (Horse saddle anesthesia).

Occasionally the herniated disc can compress all the nerves of the
legs at the same time (cauda equina syndrome), when the
symptoms described above are present, surgery is urgently needed to
avoid paralysis and loss of sphincter control.

Strengthening the muscles of the abdomen, back and buttocks with
isometric exercise.
● Reduce pressure on the discs with proper sitting position
(not straight, bent forward or with posterior tilt at 135
degree). Lift heavy objects properly, with correct posture,
with protective gear and avoid excessive weight.

● Maintain a healthy weight, avoid overweight.
● Healthy eating.

During the interrogation it is necessary to determine the area of the leg that
generates discomfort and the characteristics of the pain to determine the nerve.

compressed and be able to locate by the clinic where the herniated
disc is located, in addition a neurological examination will be performed to evaluate:
● Reflexes
● Muscle strength of each segment and muscle groups (Myotomes)
● Ability to walk
● Sensitivity in the legs by specific areas (Dermatomas)
Then some of the following tests are practiced:
● MRI is the test of choice which allows an
accurate visualization of the size of the herniation, the location and which
nerves are compressed.
● Computed tomography myelography is used when MRI is
contraindicated.
● Electromyography and neuro-conduction nerve scans help
determine the location of the nerve damage, is positive when there are
long-standing symptoms (greater than 12 weeks), when there is
damage to the affected nerve or the nerve compression is severe.

Initial management is with anti-inflammatory drugs such as ibuprofen, diclofenac,
naproxen, meloxicam, etoricoxib, celecoxib or nimesulide.
● Concomitant with anti-inflammatory drugs are required
anti-neuropathic drugs to decrease painful nerve impulses
caused by nerve compression or damage e.g. gabapentin,
pregabalin, duloxetine or venlafaxine.
● Muscle relaxants are prescribed if there is muscle spasm
.
● Opioids are used if the previously described medications do not
improve the pain, e.g. oxycodone, codeine, hydrocodone, tramadol.
● Cortisone blocks or injections at the spinal level, this is done
when the pain does not improve with a 2-3 week course with

oral medications, this is performed guided by fluoroscopy (x-rays) is
performed as a diagnostic and therapeutic test, because in many people
improve pain with this.
● Physical therapy to strengthen the muscles of the abdomen, back and gluteal
with isometric exercise, also avoid excessive weight loads and
take care of the postures of the spine in daily activities.
● Few people require surgical management, this is performed in the following cases:

● Pain not controlled either with analgesics or injections
spinal.
● Loss of sphincter control.
● Loss of leg strength.
● Loss of mobility in a part of the leg.
● Difficulty standing or walking.

There are different surgical techniques, the objective of any of these is to release
the pressure on the nerve by removing the herniated disc fragment that
compresses it. There are 2 techniques which are open microdiscectomy or spinal endoscopic surgery
.

It is very possible that intercorporal fusion is required, it is performed when there are
other diseases that accompany the hernia such as scoliosis,
spondylolisthesis (displaced vertebra) or if the back pain is more severe
than the pain in the leg.

Apply physical means with cold compresses for the first 3 days, on day 4
switch to heat to relieve muscle tension caused by the hernia.
● Avoid excessive bed rest as it increases joint stiffness and causes
muscle weakness, alternate 30 minute breaks and then perform
gentle physical activity, do not engage in activities that increase pain.
● Resume activities gradually with slow and
controlled movements, mainly when bending the body forward and when
lifting heavy objects.