The spine consists of a stack of bones called vertebrae.  Spinal discs -small gel-filled balloons- rest between the vertebrae and function as cushions separating the bones.

When something abnormal happens to a disc- either it bulges or herniates- severe pain can result. A disc herniates  (ruptures ) when pressure on it causes a tear in the outer fibrous capsule and the soft inner core, which is made of a gel-like material (the nucleus pulposus), protrudes out and puts pressure on a nerve.

Discs can herniate anywhere in the spine but the most common locations are in the neck and in the low back.

In the neck, a disc herniation can cause severe pain to radiate up into the head, down the arm, or into and between the shoulder blades.

A herniated disc in the low back is a common cause of sciatic pain, which radiates down the buttocks and into the legs, usually to one side. But it can press on other nerves.  If it presses on a nerve that controls the bowel or bladder, it can result in a loss of bladder or bowel control. This is a medical emergency that calls for immediate neurosurgical intervention.

A disc can herniate abruptly and suddenly.  An example would be an accident or other trauma. Most of the time, though, it results from gradual degeneration. A portion of the disc deteriorates over time without symptoms until suddenly, a person could be engaged in a trivial activity such as  brushing their teeth or bending over to tie their shoes and that small amount of pressure on the spine is just enough to make the disc herniate into the spinal nerves.  This leads to excruciating pain.

People most at risk include those who have a genetic predisposition to the problem. Smoking can cause spinal discs to degenerate. Disc degeneration often starts early.

Magnetic resonance imaging (MRI) studies indicate that about 30% of 30-year-olds already have signs of disc degeneration. Herniated discs are most common in people between the ages of 30 and 50. In older people, the spinal discs have degenerated and flattened out too much to herniate.  Still, older people are vulnerable to other spinal problems such as osteoarthritis.

Many people assume that having a herniated disc means that they will eventually require surgery, but that is simply not true. Up to 90% of people with herniated discs recover without surgical intervention.

Conservative care begun quickly is the best route to follow in most instances.

The goal is to get the patient through the pain comfortably enough for healing to start. To reduce pain and inflammation, non-steroidal anti-inflammatory drugs (NSAIDs) can be offered along with ice packs applied to the area of injury. A cloth should be placed between the ice pack and the skin to avoid frostbite to the skin.

Chiropractic adjustment or physical therapy can also be instituted. Patients are taught specific postural techniques to help relieve pain.

For people who don't respond to conservative measures within a few days, it may be necessary for the patient to have epidural corticosteroid shots.  These usually reduce inflammation and pain and allow the patient to get started on an exercise program. Epidural shots are given as a series of three injections over a period of four- to six-weeks.

Internal disc decompression (IDD) is a computerized form of traction that is also very effective in relieving the pressure on nerve roots.  The theory is that with the amount of traction (relief of pressure) on the disc, that negative pressure eases the disc back into location away from the nerve.   There is also evidence that the gentle pumping action of IDD produces flow of oxygen and nutrients to the area leading to faster healing.

Ultra high frequency electrical stimulation can also be very useful for pain relief since much of the pain from nerve root compression is related to muscle spasm.

If the inflammation and pressure on the nerves cannot be relieved with non-invasive methods, the patient may need surgery.   Indications for surgery are severe pain that hasn't responded to other measures or progressive neurological deficits.

There are several surgical procedures available. The classic one is discectomy (micro surgery or endoscopic).  This is still considered the gold standard. The surgeon makes a small incision over the area and removes the material that is causing pressure on the nerve tissue. Endoscopic discectomy is a procedure using a small telescope through an even smaller incision to perform the operation.

The other, more radical procedures are disc replacement and spinal fusion, and there is much discussion and controversy in the world of spinal specialists right now concerning which is better. Replacement discs are made of hard plastic, metal or metal and plastic combinations, and doctors who prefer this method like it because of the motion the new disc preserves in the spine. However, there is also concern about the longevity of the disc prosthesis. If the disc fails in the future, how does the surgeon remove it without damaging the spine?

Fusion, in which two adjacent discs are fused together using bone grafts, does not present this problem but there is a different risk. Eventually the pressure that caused the first herniated disc often simply moves up another level, leading to another rupture and a second fusion.

Recovery varies according to procedure. Both involve an overnight stay and patients cannot bend for at least several weeks. After that they can resume exercise and strengthening. Replacement surgery requires two or three days in the hospital and no bending or exercise for three weeks. Fusion is also a two or three day hospital stay, but patients are told to avoid bending for six to 12 weeks (and are often in a brace) to allow the bone the time it needs to heal.

Back surgery is far from a guaranteed fix.  A large percentage of patients who undergo surgery eventually have the pain return.  Sometimes the pain is even worse. This is termed "failed back surgery syndrome" and can be a debilitating problem.  It is important to consider all options before electing to undergo surgery.

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