Lumbar disc herniation

In one minute

A lumbar disc herniation, often called a slipped disc, is a tear in one of the cushions between the bones of the lower back that lets the soft centre of the disc push out and press on a nerve. It is most common between 30 and 50, and the two lowest discs, L4-L5 and L5-S1, account for most cases. It feels like pain shooting from the buttock down one leg, often with tingling or numbness, sometimes with weakness in the foot. The story and the examination make the diagnosis; MRI (magnetic resonance imaging) confirms it. Most people improve without an operation, which is why surgery is normally not considered before 6 to 12 weeks, the window used in the surgical trials. For the rest, the fragment can be removed through a 7 mm incision with an endoscope, usually with the patient walking the same day.

What it is

Each lumbar disc is a ring of tough fibres (the annulus) around a soft, water-rich core (the nucleus). The North American Spine Society (NASS) defines a herniation as disc material displaced beyond the normal margin of the disc space that produces pain, weakness or numbness in the territory of one nerve root. Radiologists grade how far the material has travelled: a bulge (the whole disc sags outward), a protrusion (a focal bump with a wide base), an extrusion (the core has broken through the ring) and a sequestration (a free fragment has separated). The distinction matters, because the larger, worse-looking herniations are the ones the body is most likely to reabsorb.

Reports from the region often say "грыжа диска", "межпозвоночная грыжа" or simply "osteochondrosis". The first two mean herniation. The third is a broader, older term explained on the degenerative disc disease page.

Causes and risk factors

A herniation usually announces itself with one lift, twist or sneeze, but the disc has been weakening for years. A 2024 systematic review of 59 studies found the factors most consistently linked to a first herniation with nerve pain were age between 30 and 50, smoking, a higher body mass index, cardiovascular risk factors in women, and years of bending forward and handling heavy loads at work, each raising the risk by roughly 1.1 to 3.7 times.

How it develops

With age and load the outer ring develops small fissures. Under pressure, pieces of the core squeeze through them into the canal where the nerve roots run. Two things then hurt the nerve: the pressure of the fragment, and a chemical inflammation provoked by the escaped disc tissue. That is why the pain often starts suddenly and why anti-inflammatory measures help some people.

The same inflammation slowly digests the fragment. In a systematic review of 31 imaging studies, the loose types shrank most often without surgery: 96% of sequestrations and 70% of extrusions. The contained types shrank less often: 41% of protrusions and 13% of bulges. Complete disappearance was seen in 43% of sequestrations and 15% of extrusions. NASS reaches the same conclusion: most patients improve independent of treatment, and herniations often regress over time.

Symptoms

Leg pain usually dominates back pain. With L4-L5 and L5-S1 the pain runs down the back or side of the leg to the foot; tingling or numbness follows the same strip of skin. Sitting, coughing, bending and driving make it worse; lying down or walking often eases it. Weakness shows as difficulty lifting the foot or standing on tiptoe. Spinal stenosis feels different: leg pain after walking a distance that settles with sitting. Mechanical back pain stays in the back.

Diagnosis

The story and a careful examination come first. NASS recommends muscle strength testing, sensory testing and nerve stretch tests such as the straight leg raise and the crossed straight leg raise.

Imaging is not needed on day one. NICE, the English guideline body, advises against routine imaging outside specialist care and suggests it only when the result will change what is done: in practice, when leg pain persists beyond about six weeks (the mark at which imaging starts to change the plan), when an injection or operation is being considered, or when there are red flags. NASS names MRI as the most appropriate non-invasive test, with CT (computed tomography) or CT myelography as the fallback when MRI cannot be done or is inconclusive.

Words you will see in the report:

If you send us your MRI, photograph the written report and the side-view (sagittal) and cross-section (axial) T2 images at the painful level, or send the disc files. A phone photo of the screen is enough for a first opinion.

Treatment without surgery

Time is the main treatment. NASS grades non-surgical care as improving function in the majority of patients. NICE recommends staying active, a supervised exercise programme, and manual therapy only as part of a package that includes exercise; it advises against belts, traction and acupuncture.

Medication helps less than people hope. NICE warns of limited benefit and real harms from NSAIDs (non-steroidal anti-inflammatory drugs) in sciatica, and advises against gabapentinoids, oral corticosteroids and benzodiazepines for it, and against opioids for chronic sciatica; the doctor decides on any short course. An epidural steroid injection next to the inflamed root gives relief lasting two to four weeks in a proportion of patients (NASS grade A), and NICE suggests it for acute, severe sciatica. It does not shrink the disc.

How often is this enough? In the Dutch trial by Peul and colleagues, 61% of patients with severe sciatica assigned to prolonged conservative care did not need an operation in the first year.

When surgery is considered

The indications are consistent across guidelines and trials: leg pain persisting after 6 to 12 weeks of conservative care (the window in which the surgical trials below enrolled patients) with a herniation on MRI that matches the symptoms; progressive or severe weakness; cauda equina syndrome (an emergency); and pain the patient cannot live with. NICE adds that body weight, smoking and psychological distress should not be used to refuse a surgical opinion.

On timing, the evidence is consistent. In the Dutch trial, early surgery relieved leg pain faster and doubled the rate of perceived recovery, yet at one year 95% of both groups felt recovered. In the American SPORT trial (Spine Patient Outcomes Research Trial), both groups improved substantially over two years; the advantage for surgery was small on intention-to-treat analysis and clearer when patients were analysed by the treatment they actually received. NASS suggests operating within six months when symptoms warrant it, because earlier surgery is associated with faster recovery. Delay costs months of pain, not the final result.

Surgical options

Open microdiscectomy is the operation the trials above were built on: a skin incision of a few centimetres (a mean of 38 mm in the 2022 BMJ trial) under general anaesthesia, a small window in the bone, removal of the fragment, and usually one night in hospital.

Full endoscopic discectomy (PELD, percutaneous endoscopic lumbar discectomy, or PTED, the transforaminal variant) reaches the same fragment through a working tube the width of a pencil. In the 2022 BMJ trial of 613 patients, leg pain at one year was no worse and slightly better than after open surgery. 94% of endoscopic patients went home the same day, compared with 6% after open surgery. There were no dural tears in the endoscopic group against 3% in the open group. Repeat surgery within a year was 5% versus 6%. NASS, writing in 2012 before that trial, says endoscopic discectomy may be considered (a grade C recommendation), and the comparative study it cites found earlier return to work and shorter opioid use than after open discectomy. See endoscopic lumbar discectomy.

Removing only the loose fragment (sequestrectomy) gives the same reherniation rate as clearing the disc space aggressively, so NASS recommends either. NASS found insufficient evidence for adding a fusion to a first discectomy and says the best available evidence suggests the same outcome with or without it. For a herniation that returns, see endoscopic revision discectomy. Nucleoplasty and ozone injections carry insufficient evidence in the NASS review, and automated percutaneous discectomy receives only the weakest positive grade (C, may be considered).

How we treat it at spine.uz

Endoscopic spine surgery in Tashkent for a herniated disc

Send your MRI on Telegram or WhatsApp. The remote opinion is free; a doctor from the team replies by voice within 48 hours with what the images show and whether you are a candidate for waiting, an injection or an operation. The in-person consultation and the operation are paid.

When surgery is indicated we remove the fragment through a 7 mm incision, most often under local anaesthesia with sedation rather than general anaesthesia; the anaesthetist and surgeon decide per patient. No screws or implants are used. Most patients walk on the day of surgery and go home within 24 hours. We are Tashkent's first endoscopic spine team, five surgeons operating as one team, with 27,600+ endoscopic and spine operations and a complication rate well below 1% in our own series. Every patient leaves with a written team conclusion.

Recovery and outcomes

In the BMJ trial, every endoscopic patient was on their feet on the day of surgery, median leg pain at one year was 7 on a 0 to 100 scale (16 after open surgery), and 79% considered themselves recovered. In one comparative study cited by NASS, endoscopic patients returned to work at a mean of 27 days against 49 days after open discectomy. Return to sport is reported less consistently in the trials; the timing is set individually, usually after walking and daily activities are pain-free. Residual numbness fades over months and may not vanish completely.

The disc can herniate again. Repeat surgery within a year was 5% to 6% in the BMJ trial; a 2025 meta-analysis of more than a million patients pooled reoperation at 8.5% overall, 4% in the first year and about 11% between one and five years, with smoking, older age and a large tear in the disc wall as the main risk factors.

Living with it and prevention

Keep moving: NICE advises continuing normal activities rather than resting. Stop smoking and keep weight down; both raise the risk of a first herniation, and smoking also raises the risk of a repeat operation. Lift with the load close to the body and ask about changing work that involves hours of bending. Belts and corsets are not recommended. A repeat MRI to check on a herniation that has settled is not needed unless the result would change treatment.