Lumbar Herniated Disc: Doctor Answers Patient Questions

Peter Ullrich, MD

The following explanations, insights and advice about lumbar herniated discs - including diagnosing the source of the pain and how to proceed with treatment options - are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.

Patients frequently e-mail us questions about their lumbar herniated disc problems, and while we don’t provide individual responses, periodically, Dr. Ullrich will take time to respond to the more frequently asked questions and we publish the responses in this section of the site.

Please understand that the following responses to lumbar disc herniation questions represent the opinion of one physician, and are intended for informational purposes only and not as a substitute for professional medical help or advice.

Lumbar Herniated Disc Questions and Physician Responses

Question:

I know that on an MRI, the amount of disc herniation (L5 in my case) is measured in increments of millimeters (mm). Are there studies, opinions or facts that indicate which level (# of mm) of disc herniation warrants which treatment?

For example:
?mm-?mm has success with medication and non-use
?mm-?mm has success with epidural injections
?mm-?mm requires surgery

If a lumbar disc herniated to a certain level, does low back surgery become necessary, bypassing any conservative treatments?

Doctor’s response:

There is no particular mm measurement for a lumbar herniated disc that would indicate the best treatment. Instead, physicians determine the best course of treatment by looking at the patient’s clinical situation, including factors such as the amount of pain a patient has, the amount of disability, and the duration of the patient’s symptoms.

A disc herniation or bulge is usually only clinically significant if it is pinching a nerve root. It matters more where the disc is herniated (e.g. midline disc herniation rarely pinches a nerve root) and how big the person’s spinal canal is. If the canal is small, even a small disc herniation may pinch a nerve root. If the canal is large, even a sizable disc herniation may not cause any symptoms.

For leg pain due to a pinched nerve root from a lumbar herniated disc generally 6-12 weeks of conservative treatment is advisable (NSAIDs, narcotic pain medications, physical therapy, chiropractics, or epidural injections). If this fails, or the patient is in extreme pain, then surgery may be a better option to speed the recovery.

If the patient’s primary problem is back pain, it matters much more what the disc space itself looks like and rather than the amount of disc herniation. If there is a lot of wear in the cartilage and collapse of the disc space, and the patient has not found pain relief or improved function after about six to twelve weeks of aggressive non-surgical treatment, then a spinal fusion may be reasonable.

Finally, it’s important to remember that what works well for one patient with a symptomatic herniated disc may not work well for another, and patients should work with a spine specialist to determine the appropriate course of surgical and non-surgical treatments for their particular situation.

Question:

I experience numbness and tingling in my leg. I have a lumbar herniated disc at L5, which is causing sciatica. Besides an MRI, is there another test to determine if the sciatica is caused by nerve compression and to identify which nerves are being compressed?

Doctor’s response:

A CT scan can provide an image of the vertebral disc if it is sizable, but does not give quite as detailed an image as an MRI. Likewise, an EMG study (electromyography) of the leg can indicate if a muscle group is affected, but the test is non-specific and typically does not detect herniated discs. The best test to evaluate nerve compression is an MRI scan. For patients who have claustrophobia, newer MRI scanning equipment is no longer designed like a tunnel and is less likely to cause claustrophobia.

Question:

I was out of work for 17 months with lower back pain. After two years, I am still experiencing the lower back pain, and my MRI scan shows that I have a bulging disc. So far, the exercises prescribed by my doctor have not helped with lower back pain relief. What are some other options for treating a herniated disc?

Doctor’s response:

A bulging disc (often called a herniated disc) in and of itself is not necessarily painful. First, you need to obtain a more accurate diagnosis of what is causing your lower back pain. The pain may be from the actual discs or the pain may be the result of another condition. The appropriate treatment option depends on the cause of the pain. I would recommend that you meet with a spine specialist, such as an orthopedic spine surgeon, neurosurgeon or physiatrist, to obtain an accurate clinical diagnosis. Basic treatment options for low back pain caused by a bulging (herniated) disc often include medications, physical therapy, manipulation, injections and occasionally surgery or other invasive procedures.

In almost all cases of lower back pain, exercise and physical activity play an important role in rehabilitation and long-term pain relief. For this reason, it is important to meet with an appropriately-trained back health professional (such as a physical therapist) to ensure that you are performing the recommended exercises properly and to develop a home exercise program.

What next?

If you have questions about lumbar disc herniation, please use this site to find peer-reviewed health information about spinal conditions, diagnosis and treatment options. The quickest way to locate information on the site is to use the “keyword search” box located in the upper left hand corner of each page. Also, if you want to talk online with others who may be in a similar situation or exchange information with other patients with a lumbar herniated disc, please go to the Spine Forum Message Boards.

Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health’s Medical Advisory Board.