What is Lumbar Disc Herniation
In the centre of a lumbar disc sits the nucleus pulpous, a gelatinous type material. Surrounding it lies the annulus fibrosis which are layers of collagen fibres. Lumbar Disc Herniation refers to the movement of the nucleus populous through the annulus fibrosis.
When the nucleus pulpous exits the outer region of the annulus, an inflammatory response is initiated, which in addition to creating local pain can irritate the nerves which supply the leg e.g. sciatic nerve. Further, the herniated material can create physical irritation to the nerve.
To make life difficult for patients, researchers and healthcare professionals alike, Disc Herniations can occur:
- Without any symptoms
- With back pain and not leg pain
- With leg pain and/or weakness but not back pain
- With both leg pain and/or weakness and back pain
How are Lumbar Disc Herniations Treated?
Surgically
Surgical approaches aim to remove the herniated material.
There are many factors to consider with a surgical approach. Typically people with disc herniations are referred for surgical opinion when the patient experiences worsening or absolute weakness and numbness e.g. an inability to feel the foot and move the toes, which cannot be modified with conservative approaches like exercise or manual therapy.
Conservatively
In cases of disc herniation we can frequently use postures, exercise and manual therapies to reduce the pain, inflammation and sometimes the physical size of the disc bulge. This can decrease the irritation to the nerves, improving sensation and strengthening of the leg.
Typically conservative treatment is recommended for the first 3-6 months with close monitoring of symptoms to reduce the risk of long term nerve injury.
As an example a study (1) demonstrated that only 22% of patients receiving conservative treatment with sequestrated or extruded discs, went on to have surgery. The patients who did not have surgery were followed up 6+ months later and showed no signs of irreversible nerve damage.
Lumbar Disc Reabsorption
Most interestingly, there have been studies demonstrating the bodies remarkable ability to heal itself in full effect. MRI and CT scans have shown intervertebral disc herniations reducing in size and fully disappearing. This is without surgery. A phenomenon that has been termed “Reabsorption”.
Since 1984 there has been evidence of spontaneous reabsorption, with some studies showing reabsorption in 62-66% of patients with symptomatic lumbar disc herniation. Further highlighting the ability of the condition to resolve with non-surgical treatment is a study in the journal Clinical Rehabilitation (2):
- Disc Sequestration – 96% Spontaneous Reabsorption
- Disc Extrusion – 70% Spontaneous Reabsorption
- Disc Prolapse – 41% Spontaneous Reabsorption
A research paper (3) published in 2022 which reviewed the studies on this subject found scientific evidence that all types of herniation (protrusion, extrusion and sequestration) have been shown to demonstrate reabsorption.
However, extrusion and sequestration tend to have higher rates of regression and cause more problems for patients. This is because the extruded or sequestered nucleus pulpous comes into physical contact with the systemic circulation, the immune system recognizes it as a foreign body and creates a large inflammatory response which is more likely to affect the nerves and produce symptoms such as Sciatica.
References:(1) Ma et al., (2021) ‘Conservative treatment for giant lumbar disc herniation: clinical study in 409 cases’, Pain Physician, 24(5), p.E639.
(2) Chiu et al., (2015) ‘The probability of spontaneous regression of lumbar herniated disc: a systematic review’, Clinical rehabilitation, 29(2), pp.184-195.
(3) Yu et al., (2022) ‘Characteristics and mechanisms of resorption in lumbar disc herniation’, Arthritis Research & Therapy, 24(1), p.205. https://doi.org/10.1186/s13075-022-02894
