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Herniated Disc

What is a herniated disc? Leg pain and sciatica

A herniated disc is the most common condition affecting the lumbar spine and a frequent cause of lower limb pain (sciatica).

Intervertebral discs are located between the vertebrae and essentially act as shock absorbers for the spine. Each disc has a tough outer layer (called the annulus fibrosus) and a soft inner core, known as the nucleus pulposus. A disc herniation occurs when the outer ring tears and the nucleus slips into the spinal canal, pressing on a nerve (see diagram 1). In addition to mechanical pressure, the nucleus also causes chemical irritation to the nerves, resulting in inflammation and pain.

Most disc herniations occur due to sudden stress (e.g., lifting a heavy object, twisting, or bending), though they can also develop gradually without any acute event. Risk factors include:

Age: As we age, discs degenerate (much like how skin wrinkles). This degeneration is called DEGENERATIVE DISC DISEASE(many people mistakenly refer to it as a herniated disc).
Lifestyle: Lack of exercise, being overweight, and smoking all impair disc function.
Poor posture: Repetitive lifting, twisting, and poor posture put strain on the discs.

What are the symptoms?

Common symptoms include:

Acute lower back painthat worsens with coughing or sneezing. Muscle spasms or cramps in the lower back. The back pain often subsides when leg pain begins.
Sharp leg pain: Pain that starts in the buttock, radiates past the knee, and may extend to the calf or foot.
Leg weakness or numbness: The patient may not be able to walk on their heels or toes due to muscle weakness.

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How is it diagnosed?

Diagnosis is mainly based on:

Patient history
Physical examination– focused on the nerves of the lower limbs, including motor function, sensation, and reflexes. Specific nerve tension tests (like straight leg raise or prone knee bend) help identify nerve root compression.

The preferred imaging test is an MRI, though a CT scan may be helpful in some cases. Electromyography (EMG) usually doesn’t add significant information and is often painful and invasive.

What is the treatment?

Most herniated discs do not require surgery. For the majority of patients, symptoms improve within 2–3 weeks. In about 10–20% of cases, pain persists longer. Unfortunately, we can’t always predict who will respond to conservative treatment. Therefore, initial treatment is usually non-surgical, and surgery is considered if symptoms do not improve. Severe leg weakness is a sign for immediate surgery to preserve nerve function.

Conservative Treatment

Lumbar support belt(a regular waist brace is enough)
Heattherapy (cold may help some, but warm compresses are generally recommended)
Medication:

Anti-inflammatories (NSAIDs or corticosteroids)
Painkillers (non-opioid and opioid)
Neuropathic pain meds (Gabapentin, Pregabalin)
Physiotherapy: Early initiation is effective for intense pain.

Conservative treatment relies on a combination of anti-inflammatory drugs, muscle relaxants, and opioid painkillers to manage acute pain. Heat (and sometimes cold) applications to the lumbar area are also recommended for 24–48 hours.

Bed rest is strongly discouraged. Prolonged immobility may cause complications like thrombosis. Painkillers are given to enable movement. Even severe pain can be managed with proper medication, sometimes requiring stronger doses.

Short-term use of a lumbar belt can relieve symptoms without causing muscle atrophy. Injections are unnecessary at home and are mainly reserved for emergency use in hospitals. While injections work faster, oral medication is equally effective, with only a slight absorption loss (~5%).

Physiotherapy should begin as soon as pain appears. Once the pain is gone, therapy offers little additional benefit. Traditional physiotherapy is generally more effective than alternative treatments like chiropractic, osteopathy, or acupuncture.

Surgical Treatment

If conservative treatment fails, and the patient continues to experience severe pain or signs of neurological damage (e.g., leg weakness), surgical intervention is recommended. The aim is to remove the disc fragment pressing on the nerve—a procedure called discectomy.

Modern discectomy is performed using a microscope (microdiscectomy) through a small incision (via a 2 cm tubular retractor), minimizing muscle trauma and blood loss. Patients recover much faster compared to traditional surgery, with minimal complications.

Conservative treatment is typically continued for up to a month before surgery is considered, although this period may be shortened based on patient discomfort and the high success rate of microdiscectomy.

Spinal fusion is rarely required and only in cases of persistent low back pain combined with sciatica or other spinal issues. Lumbar disc replacement has not shown clear advantages over traditional methods.

Minimally Invasive Discectomy

This includes procedures like:

Percutaneous discectomy(needle insertion to destroy the disc): using RF, laser, heat (IDET), or mechanical removal
DiscoGel injection(alcohol-based gel): popular in Greece, though with limited evidence and ~50% reported success
Endoscopic discectomy: effective in selected cases, but not suitable for large disc herniations or free disc fragments, and requires high surgical expertise

Postoperative Recovery – Is Physiotherapy Needed?

After surgery:

Leg pain usually disappears immediately
Numbness and weaknessmay take up to 6 months to improve
Patients typically get up the same dayand go home the same or next day
Incision pain is managed with medication
Rest at home is recommended for the first week, with limited activity
Driving and going outare allowed after 4–5 days
For the first 6 weeks, avoid bending, twisting, or lifting
Walking is encouraged(20–30 minutes per day)
After 6 weeks: light aerobic activity(treadmill, cycling) is allowed
After 3 months: contact sportsmay be resumed
Return to workis expected about 10 days post-surgery, with the exception of heavy lifting or bending

Χειρουργός Σπονδυλικής Στήλης

Ο Χειρουργός Σπονδυλικής Στήλης/ Σκολίωσης Δρ. Ηλίας Χαρ. Παπαδόπουλος γεννήθηκε και μεγάλωσε στην Αθήνα. Αποφοίτησε με Άριστα από την Ιατρική Σχολή Αθηνών το 1994 και στη συνέχεια ειδικεύτηκε στην ορθοπαιδική, στην Α’ Ορθοπαιδική Κλινική του Πανεπιστημίου Αθηνών.