A herniated disc of the lumbar spine is the diagnosis that brings most people to a neurosurgical practice for the first time. The words sound like an operation. In fact, the great majority of these herniations resolve on their own, and most patients with this finding are not operated on. This page explains what has happened and which paths are open to you.
In the vast majority of cases a herniated disc is not a reason for an operation, but a reason to give yourself a few weeks — and to know the few warning signs where waiting would be wrong.
What is it?
Between the vertebral bodies lie the intervertebral discs: a soft, gel-like core inside a firm fibrous ring. If the ring tears, core tissue can escape backwards into the spinal canal, where the nerve roots to the legs run. That is the herniation. If the tissue presses on a root or irritates it through the accompanying inflammation, the typical symptoms in the leg arise. The two lowest discs, L4/5 and L5/S1, are most often affected because they carry the most weight.
In the report, radiologists distinguish between a bulge, a herniation and a detached fragment (sequestration); the terms are explained on our page on understanding your MRI report. The important point is this: a herniation on the scan is not yet a disease. Many people have one without ever noticing it.
What symptoms occur?
The leading symptom is a pain that runs from the buttock into the leg, usually to below the knee, along a particular strip — commonly known as sciatica. It gets worse when you cough, sneeze or strain, when you sit for long periods and when you bend forwards. Added to this are tingling or numbness, sometimes a weakness: the foot or big toe can no longer be lifted, or you cannot stand on your toes. Back pain may be absent; a leg that hurts more than the back is typical.
The pattern reveals the affected root: L5 supplies the outer side of the lower leg, the top of the foot and the big toe; S1 the back of the leg, the outer edge of the foot and the sole. Herniations at higher levels are less common and cause symptoms at the front of the thigh.
Causes
Over the years the disc loses water, the fibrous ring becomes more brittle and develops small tears — a normal ageing process. The herniation itself then often occurs during an ordinary movement: bending, twisting or lifting, sometimes with no identifiable trigger at all. That movement is the trigger, not the cause. Predisposition and years of heavy strain play a part. People from the age of thirty onwards are most often affected, men about twice as often as women.
How is it diagnosed?
The diagnosis emerges from the consultation and the examination: where exactly does it hurt, since when, what makes it worse? We test the strength of the muscles that lift the foot and toes, standing on the toes and on the heels, reflexes, sensation and the nerve stretch signs — if raising the straightened leg brings on the familiar pain, that points to an irritated root. This tells us which root is affected and how severely.
Magnetic resonance imaging (MRI) is the imaging method of choice, but not immediately for everyone. It is needed if there are warning signs, if there is paralysis, and if there has been no improvement after about six to eight weeks and an injection or operation is under discussion. The scan must match the examination: a herniation at L4/5 does not explain pain in the area supplied by S1. An X-ray does not show the disc.
Warning signs
The vast majority of herniated discs are not an emergency. Three signs are: numbness around the buttocks and the area between the legs, a new problem with bladder or bowel control, and paralysis that increases within hours or days. A foot that suddenly catches when you walk should be examined the same day. More on this on the page Warning signs.
Conservative treatment
Treatment without an operation begins with an explanation: what has happened, why it hurts and why it will in all likelihood get better. Bed rest does not help and delays recovery. Keep moving as far as the pain allows; walking is almost always possible.
- Painkillers — anti-inflammatory medicines for a limited time at the lowest effective dose; for pronounced nerve pain, medicines that act on nerve excitability. Stronger painkillers only briefly and with a clear plan.
- Physiotherapy — guidance on movements that relieve the strain, later strengthening of the trunk and back. Heat, if it helps.
- Targeted injection at the nerve root (periradicular therapy, PRT) — under image guidance, an anti-inflammatory medicine is injected directly at the irritated root. This can ease the pain for a few weeks and bridge the time during which the herniation resolves. Whether it avoids an operation cannot be predicted in the individual case. We offer this treatment in our practice.
- Multimodal pain therapy — for symptoms lasting months, a combined programme of exercise, pain medicine and psychology may be considered.
When an operation is considered
An urgent operation is performed for cauda equina syndrome — numbness in the area between the legs together with bladder or bowel dysfunction — and for paralysis that is functionally significant or increasing rapidly, for instance when the foot can no longer be lifted against resistance. Here time matters, because nerve tissue under sustained pressure does not always recover.
A planned operation is considered if the leg pain persists for six to twelve weeks despite consistent treatment, the MRI findings fit, and you want the procedure. Back pain alone is not a reason. What the operation achieves: on average, those who are operated on have less pain sooner; after about a year, studies mostly show only a small difference compared with those treated conservatively. The decision is a trade-off between time and risk — and it is yours.
Surgical options
The standard procedure is microsurgical decompression of the nerve root. We offer this procedure. Its aim is limited and clear: to remove the tissue that is pressing on the root. The disc is not “repaired” and not replaced.
- ProcedureUnder general anaesthetic and lying face down, a small window is created between the vertebral arches through a skin incision a few centimetres long, using the operating microscope. The root is exposed, the herniated tissue removed, and the rest of the disc remains. The procedure usually takes about an hour, and the hospital stay is usually a few days.
- RisksAs with any operation: infection, bleeding, thrombosis and the risks of anaesthesia. Specific to this procedure: an injury to the membrane around the nerves with leakage of spinal fluid, rarely damage to the root with sensory disturbance or weakness, scarring around the root, and a recurrent herniation at the same site, which occurs in a proportion of those operated on. Pre-existing numbness may remain, and even after a successful procedure the pain does not always disappear completely. Which of these matter most in your situation is something we discuss before the procedure.
- AftercareGetting up on the day of the operation or the day after; walking is encouraged. No heavy lifting and no twisting movements under load for a few weeks, physiotherapy once the wound has healed, then exercise on your own. How long you are off work depends on your job. A follow-up check with us is part of the process.
Endoscopic procedures through a thin working sleeve with a camera may be considered where the findings are suitable. A fusion is not indicated for a simple herniated disc; it is considered only where instability has been demonstrated.
Alternatives
The most important alternative is supervised waiting: monitoring of strength and sensation, pain treatment, exercise, and an injection if needed. If the pain threatens to become chronic, multimodal pain therapy is an option. If you have been advised elsewhere to have an operation, you can obtain a second opinion from us.
What to expect
The course is usually favourable. In one survey, around 60 out of 100 people with sciatica had mild to moderate pain that improved markedly within three months; up to 25 out of 100 had symptoms again within a year. What you can do yourself: walk every day, break up periods of sitting, and once the pain has subsided, strengthen your trunk and back and keep at it. And check your foot once a day: stand on your heels, stand on your toes, lift your big toe. If that gets weaker, get in touch.
Frequently asked questions
Does a herniated disc have to be operated on?
In the vast majority of cases, no. An operation is necessary where there are warning signs such as bladder dysfunction, numbness in the area between the legs or increasing paralysis. Otherwise it is an option that is weighed up together after six to twelve weeks of unsuccessful treatment.
Does the herniation disappear from the MRI again?
Often, yes; the body breaks down herniated tissue over months. More important than the scan, however, is how your symptoms develop.
Can I do sport?
Exercise is part of the treatment. In the acute phase, walking, swimming and cycling are usually well tolerated; sport involving jumping, impact or heavy lifting waits until the leg pain has subsided.
How long does the numbness last?
Sensation recovers more slowly than the pain, often over months; some residual numbness may remain, even after an operation. Numbness that is stable and not increasing is unpleasant but no cause for concern.
Do I need a referral?
No. It is useful, though, because it gives us your history. Bring any existing scans on CD; everything else is on the page Your first appointment.