A disc herniation refers to a protrusion of one or more cartilaginous discs that lie between the individual spinal bones (vertebrae). A herniated disc can press on a root of a spinal nerve and cause pain in the neck, arm, lower back or leg.
- Intervertebral = between vertebra
- Cervical (C) = Neck
- Thoracic (T) = Chest
- Lumbar (L) = Lower back
- Sacral (S) = Pelvis
- Coccygeal (Coc) = Tailbone
- Radiculopathy = a disease of the spinal nerve roots (from Latin radix = spinal root; -pathy = disease); also called radiculitis
Intervertebral Disc Anatomy and Function
Intervertebral discs are the cartilages between each vertebra in the spine, except between the first two in the cervical spine (C1 and C2) and the vertebra in the sacrum, which are fused together. The vertebra in the tailbone (coccyx) may or may not be separated by discs. The discs enable bending of the spine and act as shock absorbers.
Discs are designated by the two adjacent vertebrae; for example, the disc between the 4th and 5th cervical vertebra is designated C4-C5 and the disc between the 5th lumbar and 1st sacral vertebra L5-S1.
A disc consists of a firm outer fibrous ring (annulus fibrosus) and a soft, jelly-like center (nucleus pulposus) (Picture 1).
Picture 1. Intervertebral disc
31 pairs of the spinal nerves emerge from the spinal cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal .
The spinal nerves C1 to C7 emerge above their respective vertebrae, for example, the nerve C1 emerges above the 1st cervical vertebra. The C8 nerve emerges between the C7 and T1 vertebrae and the remaining nerves (thoracic, lumbar, sacral and coccygeal) emerge below their respective vertebrae, for example, the nerve T1 emerges below the 1st thoracic vertebra. The spaces between the vertebra through which the spinal nerves exit the spinal cord are called intervertebral or neural foramina.
Bulging vs Herniated Disc
Strong or repeating forces that act on the spine can damage the intervertebral discs :
- In a bulging disc, a large part of the disc circumference bulges out. Bulging discs are not torn, they rarely press on the spinal nerves and rarely cause pain or other symptoms.
- In a herniated disc, the soft center pushes the outer fibrous ring out in a non-symmetrical manner; it may or may not press on the spinal nerve root or spinal cord and may or may not cause pain.
- Check for more herniated disc-related terms (as found on MRI reports).
Picture 2. Bulging vs herniated disc
Causes and Risk Factors
Degenerative Disc Disease (DDD) or Spondylosis
Degenerative disc disease (DDD) is not really a disease but an age-related wear and tear of the discs. With age, the discs lose some water (disc dehydration or desiccation) and hence some shock absorbing capability, which makes them more prone for herniation. DDD can occur in people as young as 20 years of age [4, anecdotal reports], which suggests that genetic and other factors may be more important than age [3,36].
Spondylosis is a broader term than DDD and includes the degeneration of all parts of the spine: the discs, vertebra and the joints between the vertebra (spinal osteoarthritis) .
Acute or Chronic Injury
A bulging or herniated disc can result from a single injury, for example, in sports like football, gymnastics, rugby, diving or weight lifting (especially deadlift), lifting a heavy object, fall from a height or car accident (whiplash injury), or from repetitive prolonged sitting, driving, bending, lifting or heavy physical work [4,31].
Risk factors for a herniated disc include old age, a family history of disc disease, pregnancy, being overweight, sedentary lifestyle, psychical stress and smoking [1,25,81].
A bulging disc by itself rarely causes pain or other symptoms.
Symptoms of a herniated disc:
- Discogenic pain due to tears and inflammation in a disc: deep, aching pain in the neck, upper or lower back, usually bilateral — on both sides of the spine, but not in the limbs .
- Radicular pain due to an inflammation or compression of a spinal nerve root: burning, shooting, electric-like pain in the upper or lower limb on one or both sides, which can be associated with abnormal sensations, such as tingling and numbness, and muscle weakness; rarely, these symptoms appear in the absence of pain [63,66].
- Muscle spasms as a reaction to a pinched nerve: sudden crampy pain along the neck or lower back spine lasting for several minutes [2,67].
You may or may not feel herniated disc. A small disc herniation can cause severe pain and a large herniation may cause no pain . The pain tends to be recurring — it may come in flares that may last from few days to few months .
Common associated symptoms are depression and weight loss due to loss of appetite caused by pain.
A doctor can often make a diagnosis of a herniated disc from the patient’s history and physical examination . Imaging or other investigations are needed after severe trauma, before surgery or when other serious conditions, such as bone infection or cancer, are suspected .
The neck or back X-ray is a routine investigation in individuals with neck or back pain that does not improve after 6 weeks of physical therapy and in which a surgery is planned . An X-ray cannot show a bulging or herniated disc but may show a narrowed space between the vertebra due to disc collapse, bone spurs (osteophytes), broken vertebra, spondylolisthesis, infection (osteomyelitis) and tumors [7,52]. When a herniated disc in the absence of severe trauma is strongly suspected, an X-ray can be avoided .
Magnetic resonance imaging (MRI) is the study of choice and the most detailed investigation before surgery for most individuals with herniated discs in the neck  and lower back [7,52,53]. Most individuals who do not plan to have a surgery do not need an MRI. An MRI with a contrast (gadolinium) can better show nerve root inflammation than regular MRI .
Types of bulging and herniated discs as described on MRI reports [52,57,59]:
- Circumferential bulging disc: 50-100% of the disc circumference bulges out; such a disc rarely presses upon a nerve.
- Minimal disc bulge is a small bulge that does not press upon the nerve root or spinal cord.
- In focal herniation, less that 25% of the disc circumference bulges out in an asymmetrical fashion.
- In diffuse or broad based herniation, 25-50% of the disc circumference is involved.
- In disc protrusion (contained herniation), the soft disk center pushes the outer fibrous ring out but does not break it.
- In disc extrusion (non-contained herniation, prolapsed, slipped, torn or ruptured disc), the soft disc center is squeezed out through a torn fibrous ring (annular tear).
- In disc migration, a part of a disc moves to the spinal level other than one of the original disc or to the back side of the hard spinal cord membrane (dura mater).
- In disc sequestration, a part of a disc (a fragment) loses connection with the main disc body.
- A collapsed disc is a shallow disc that has shrunk vertically.
- Soft disc means acute extrusion of the soft disc center (nucleus pulposus), usually due to an injury.
- Hard disc means chronic pressure of the hard fibrous ring (annulus fibrosus) or bone spurs upon a nerve root.
- Spinal stenosis is a narrowing of the spinal canal, for example, due to a herniated disc: 1/3 narrowed canal = mild; 1/3-2/3 narrowed = moderate; >2/3 narrowed = severe.
- Depending on the orientation, a herniation can be:
- Posterior or central (pointing backward toward the middle of the spinal cord; can cause spinal stenosis; often causes only pain in the neck or back without pain in the arm or leg) 
- Posterolateral or paracentral (pointing backward to the right or left nerve root; can pinch a nerve root) 
- Foraminal (pointing toward an intervertebral foramen, through which a spinal nerve exits the spine)
- “Far lateral” (right or left beyond the intervertebral foramina; can result in a nerve entrapment on the same, upper or lower level; MRI may miss it)
- Intravertebral (pointing vertically into the adjacent vertebra)
Both false positive or false negative MRI results are possible: disc changes that seem to be severe on MRI may cause no symptoms and changes that seem to be mild may cause severe pain [7,10,54].
CT Scan With or Without Myelogram
Computed tomography (CT) can often show bulging and herniated discs equally well as MRI . The advantage of a CT is a lower cost; the main disadvantage is a high radiation exposure.
CT can show calcified discs, especially in the thoracic spine, better than MRI [52,55]. Herniated discs can be calcified or not . Disc calcification can also appear in ankylosing spondylitis and some other disorders .
CT with myelography (injecting a contrast substance into the spinal canal) can be done before surgery to evaluate the extent of spinal stenosis , after severe trauma, when multiple herniated discs, spondylolisthesis or tumors are suspected or when an MRI is contraindicated (in claustrophobia), not available or too expensive [52,66]. Myelography can cause a severe headache after the procedure .
When MRI or CT image results are not clear, a selective spinal nerve root block can help to find out which exact spinal nerve is affected .
Discography (diskography) means an injection of the saline into a disc. The aim of the investigation is to check for discogenic pain, that is pain that arises from the disc in the absence of apparent nerve root damage. Pain during an injection that is similar to your existing pain suggests the disc origin of the pain . Discography can be done when the cause of the lower back pain remains unknown after other investigations. Complications may include a nerve root injury and infection [52,55]. False positive and negative results are possible and some researchers doubt in the usefulness of this investigation .
Discography with a contrast followed by CT may better show tears in the fibrous ring (annulus fibrosus) than MRI .
An EMG can be used to test muscle function to check if a herniated disc detected by MRI is the actual cause of pain: when both MRI and EMG are positive, the disc herniation is very likely the cause of pain [54,58]. There is insufficient evidence of the usefulness of EMG in diagnosing cervical radiculopathy .
Herniated discs and pinched nerves by themselves do not cause any typical changes in blood or urine tests . Sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, immunoglobulins and white blood cells can be checked to detect rheumatoid arthritis, ankylosing spondylitis, cancer or kidney inflammation .
There is insufficient evidence of the effectiveness of physiotherapy in reducing pain or long-term outcome of herniated discs [81,82].
- For acute mild or moderate pain:
- Nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin, celecoxib, diclofenac, diflunisal, etodolac, flurbiprofen, ibuprofen, ketoprofen, ketorolac (for max 5 days), mefenamic acid, meloxicam, naproxen, piroxicam or sulindac. Different individuals react differently to various NSAIDs.
- Oral glucocorticoids (steroids): prednisone for 1-2 weeks. Steroids can help in pain but they do not seem to improve the course of a disease.
- For severe acute pain lasting <2 months:
- Tramadol or narcotics (opioids), such as codeine, hydrocodone, oxycodone, propoxyphene for a short time
- For chronic pain:
- Tricyclic antidepressants (amitriptyline, doxepin)
Muscle relaxants cyclobenzaprine or orphenadrine may reduce pain caused by muscle spasms.
The anticonvulsants gabapentin may help relieve radicular  and discogenic  pain but can have significant side effects (dizziness, dry mouth, nausea, headache).
According to one 2007 review, there is insufficient evidence of the effectiveness of medications in reducing symptoms or long-term outcome of a herniated disc .
Indications for surgical treatment of herniated discs [1,58]:
- Spinal stenosis
- Lack of effect of conservative treatment for 6-12 months or progressing worsening of symptoms
- Red flag (emergency) indications: bladder or bowel incontinence, progressive neurological problems, excruciating pain or sensory loss between the legs (in the perineum)
In general, surgery is more effective when the main problem is a limb pain rather than neck or lower back pain .
Types of surgery:
Discectomy is a surgical removal of a damaged/herniated part of the disc . According to one source, discectomy has a high success rate when the herniation is more than 8 mm wide and a low success rate when it is less than 5 mm wide and when the pain in the leg is greater than the pain in the lower back .
- Open discectomy is a removal of a part of the disc through an incision in the front or back of the neck or in the lower back.
- Microdiscectomy is a small discectomy with the help of an operating microscope.
Spinal fusion includes a total removal of one or more discs and their replacement with bone grafts from your own pelvis (autograft), from another person (allograft) or with a synthetic disc to prevent painful spinal movements [12,60,79]. Spinal fusion with instrumentation includes using metal screws, rods or cages, which may be later removed. The downsides of the spinal fusion are reduced mobility of the spine and increased risk of herniation in the adjacent discs.
Laminectomy or spinal cord decompression is a removal of the rear part of a vertebra called lamina to widen the spinal canal and reduce the pressure from a herniated disc or bone spurs on the spinal cord . The surgical approach is from the back of the neck or lower back. Lumbar laminectomy is often effective in those with leg pain, but less likely in those who have only pain in the lower back . Laminoplasty is a reconstruction rather than removal of the lamina .
Foraminotomy and foraminoplasty are two techniques used to widen an intervertebral foramen–an opening through which a spinal nerve exits the spine–to decompress a pinched nerve .
Corpectomy is the removal of all or a part of the vertebral body (corpus), usually along with two adjacent damaged discs [79,87].
Total disc arthroplasty or artificial disc replacement means the replacement of a damaged disc with a synthetic disc (prosthesis) [12,60].
Minimally invasive surgery includes outpatient procedures that can be done under local anesthesia. Some of these procedures are still in the experimental phases and may have a higher recurrence rate than classical surgical techniques.
- Laser discectomy is a burning of a central portion of the disc by a laser conveyed through a needle inserted through the back muscles .
- Percutaneous endoscopic lumbar discectomy (PELD) 
- Selective endoscopic discectomy (SED) 
- Nucleoplasty 
- Chemonucleolysis 
- Electrothermal methods: intradiscal electrothermal therapy (IDET)  and disc biacuplasty 
Surgery Complications 
Complications of surgery of a herniated discs are rare but can include:
- During surgery: an injury of nerve root, spinal cord, neck or abdominal organs
- Days/weeks after surgery: infection of the operative wound, disc or vertebra, spinal stenosis, sacroiliac joint syndrome, myofascial syndrome, cauda equina syndrome, thrombophlebitis, pulmonary embolism or, rarely, paralysis, stroke or death
- Months/years after surgery: herniation recurrence in the same or adjacent disc
Herniated Disc in the Neck (Cervical Radiculopathy)
The most commonly herniated discs in the neck are C5-C6, which can press on the spinal nerve C6, and C6-C7, which can press on the nerve C7 [29,41].
Picture 3. Typical pain distribution in
a herniated disc in the neck spine
- Pain at the back of the neck or head or between the shoulder blades associated with neck stiffness [27,29,42].
- Pain due to a pinched nerve in the shoulder girdle, upper arm or chest on one or both sides and, rarely, in the hand or fingers; it can appear weeks after the onset of the neck pain and is often associated with tingling, numbness or weakness in both an arm and forearm [26,27,29,33]. Arm pain can be present in the absence of neck pain and vice versa .
- The pain in the neck or arm can be aggravated by bending the head backward or sideways (tilting) [26,27,68].
- Pain can be relieved by lying on the back  but may be worse in the morning .
Chart 1. Symptoms of Pinched Nerves in the Neck and Upper Back
Pain and Paresthesia Distribution (Dermatome)
Affected Muscle Functions
|C2||C1-C2||Back of the head, ear, the angle and bottom of the jaw||Bending the neck forward and backward|
|C3||C2-C3||Back or front of the neck; pain behind the eyes||Tilting the head toward the shoulders|
|C4||C3-C4||Base of the neck||Elevation of the shoulders (shrugging)|
|C5||C4-C5||Collar bones, front of the shoulder, base of the neck, outer side of the upper arm||Raising an arm forward or sideways|
|C6||C5-C6||Back and outer side of the shoulder, upper part of the shoulder blade, outer side of the upper arm and forearm, a thumb||Raising an arm forward, backward or sideways|
|C7||C6-C7||Shoulder blade or between the shoulder blades, back of the upper arm and forearm, 2nd and 3rd finger and the related part of the hand||Wrist flexion and extension|
|C8||C7-T1||Shoulder blade or between the shoulder blades, inner side of the upper arm and forearm, 4th and 5th finger and the related part of the hand||Bending the fingers|
|T1||T1-T2||Upper part of the shoulder blades, upper chest, inner side of the upper arm and forearm||Spreading the fingers|
|T2, T3||T2-T3, T3-T4||Lower part of the shoulder blades, upper chest, armpit (axilla)|
|T4||T4-T5||Back and chest at the breast nipples level|
|T5-T9||T5-T6 to T9-T10||Below the shoulder blades, flanks, between the nipples and the belly button|
|T10||T10-T11||Lower back and abdomen at the belly button level|
|T11, T12||T11-T12, T12-L1||Lower back, above the hips, abdomen bellow the belly button|
Chart 1 sources: [18,19,20,22,24,29]. NOTE: There may be a considerable overlapping between dermatomes or an absence of any specific pattern; nerves on multiple levels can be pinched .
Physical Examination: Provocative Tests and Signs
- Shoulder abduction. While sitting, place a hand of the affected arm on the top of the head; pain relief in the arm suggests cervical radiculopathy [26,28].
- Valsalva maneuver. Take a deep breath, pinch your nose and try to forcefully exhale through it for 2-3 seconds; pain radiating down the arm suggests a herniated disc . The test is often false negative (no pain despite the presence of a herniated disc), but is highly specific (pain speaks for a herniated disc and not some other disease with a great certainty .
- Spurling’s test. You sit with the neck extended and rotated slightly to one side and a doctor applies a downward pressure on your head: if you feel pain radiating down your arm, it is very likely you have a pinched nerve in the neck, but a negative test (no pain) does not exclude it; the test is often negative in chronic disc degeneration [27,44,69].
- Tender points along the neck spine, along the medial shoulder blade border or in the upper arm can result from a herniated disc .
- Active trigger points in the neck and upper back that elicit pain in distant body areas upon pressing were found in 51% of individuals with cervical radiculopathy in one study .
Complications of Herniated Discs in the Neck
A large disc herniation in the neck can cause a damage to the spinal cord (cervical myelopathy) possibly resulting in paraplegia, tetraplegia, bladder incontinence or recurrent urinary tract infections .
Differential Diagnosis for Cervical Radiculopathy
Conditions that can have similar symptoms as cervical radiculopathy [34,36,43]:
- Wry neck or torticollis
- Cervical sprain and strain or whiplash syndrome after a car or motorbike accident
- Cervical myofascial pain
- Carpal tunnel syndrome
- Shoulder disorders, such as rotator cuff injury or adhesive capsulitis (frozen shoulder)
- Spinal osteoarthritis or cervical facet syndrome
- Coronary heart disease with angina pectoris
- Fibromyalgia (tender points, fatigue)
- Neuropathy due to diabetes, alcoholism or vitamin B12 deficiency
- Rheumatoid arthritis or systemic lupus erythematosus (SLE) 
- Thoracic outlet syndrome and other disorders of the brachial plexus
- Shingles (itchy rash)
- Polymyalgia rheumatica
- Polymyositis and dermatomyositis (muscle weakness, skin rash)
- Transverse myelitis–an inflammation of the spinal cord due to autoimmune disorders, such as multiple sclerosis, rheumatoid arthritis or SLE
- Complex regional pain syndrome (CRPS) 
- Discitis (an infection of a disc), usually associated with osteomyelitis (an infection of a vertebra)
- Paget’s disease of the bone
- Syringomyelia – a cyst in the spinal canal
- Tumors : a tumor in a nerve root (schwannoma), Pancoast tumor (cancer at the top of the lung) , thyroid or esophageal cancer, lymphoma
Treatment Options for Herniated Discs in the Neck
Conservative, natural treatment (partial rest, immobilization, physical therapy) alone without any medications or surgery is very often successful in treating cervical radicular pain [62,63,64]. Symptoms may improve spontaneously and completely within few months without any specific treatment at all [66,74,76].
1. Partial Rest
Individuals with a recent cervical radiculopathy should avoid excessive neck movements and certain head positions until their pain goes away . Bed rest is usually not needed.
2. Immobilization: Cervical Collar
A cervical collar is intended to limit neck movements and thus speed up recovery in individuals with acute cervical radiculopathy. A soft or semi-hard cervical collar during the day for 1-3 weeks and partial rest is often associated with faster pain relief than rest alone [26,63,74,75]. NOTE: A long-term collar use (> a month) can weaken the neck muscles .
3. Home Remedies
- Moist heat pads or ice packs can help relieve acute pain [61,63].
- Molded cervical pillow at night can help prevent excessive neck movements.
- Adjusting a desktop or using an ergonomic chair can help improve body posture .
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, and opioids (in severe pain lasting <8 weeks) may help relieve pain .
5. Physiotherapy and Exercise Programs
Physical therapy and relative rest for 6 weeks can reduce acute neck and arm pain more efficiently than rest alone [74,75] but does not necessary affect the long-term course of a disease .
Therapy in the first 6 weeks (3-5 times a week) after the onset of pain can include [63,68]:
- Neck-school: a small group education and stretching exercises within the painless range of motion of the neck 
- Neck massage
- When the pain improves, graded strengthening exercises, such as chin-to-chest, side-to-side swivel, eyes-to-the-sky and ear-to-shoulder, can be started .
A good sign of the effectiveness of exercise is a gradual movement of symptoms from the upper limbs toward the spine (centralization); the movement of symptoms from the spine toward the upper limbs (peripheralization) speaks for wrong exercising regime or poor body posture .
Surgery of cervical radiculopathy can be considered when severe pain, muscle weakness or neurological signs persist after 6 weeks of conservative therapy . Surgery can provide quick pain relief, but long-term results may not be better than with conservative treatment .
Surgical techniques with an approach from the front of the neck include anterior cervical foraminotomy (ACF), anterior cervical discectomy (ACD), or corpectomy, anterior cervical discectomy with vertebral fusion (ACDF) and cervical total disc arthroplasty (TDA). Techniques with an approach from the back of the neck include laminoplasty, laminectomy and posterior foraminotomy and/or discectomy [62,65,66].
Recovery time after surgery :
The recovery time depends on the extent of damage to your spine before surgery and the type of surgery, but you can expect:
- 1-2 days stay in the hospital, during which you can eat normally and walk
- Return to work within a week
- Wearing a cervical collar for a week or longer
- Difficulty swallowing or hoarseness for few weeks
- 4-6 weeks of restriction of activity and, sometimes up to 16-12 months of restriction of your neck movements
- Physical therapy with strengthening exercises from the week 4-6
7. Treatments With Insufficient Evidence of Effectiveness
Manual or mechanical traction probably provides only temporary relief and is not likely effective in relieving chronic pain lasting >3 months [61,63].
Manual or mechanic spinal manipulation is either not recommended or there is insufficient evidence of its long-term effectiveness [63,64,66,77]. Complications, while rare, may include further nerve root damage, myelopathy and worsening of pain [63,64].
Epidural steroid injections may provide a short-term pain relief in individuals with an MRI-confirmed cervical radiculopathy [61,62] but may not improve the long-term outcome of the disease , and may, rarely, be associated with a serious damage to the spinal cord or brainstem, so some doctors do not recommend them .
A selective nerve root block with a local anesthetic may help relieve a headache in some individuals with cervical radiculopathy .
A cervical epidural nerve block may help reduce pain due to inflammation of the discs or nerve roots [61,62].
Prolotherapy (trigger-point injections) may relieve myofascial pain in the neck muscles .
Other treatments with insufficient evidence of effectiveness include acupuncture [66,71,73], yoga [71,72] and Pilates .
A dermatome is a skin area mainly supplied by the nerves from a single nerve root. Pain, tingling or numbness in a certain dermatome suggest which spinal nerve may be affected.
Picture 4. Dermatome map
C = cervical (blue and green); T = thoracic (red)
L = lumbar (yellow); S = sacral (brown); Coc = Coccygeal
Herniated Disc in the Lower Back (Lumbar Radiculopathy)
The most commonly affected discs in the lumbar spine are the disc L4-L5, which can press on the spinal nerve root L4, and the disc L5-S1, which can press on the root L5 .
- The first symptom is usually deep aching pain in the middle of the lower back that becomes better in few days.
- Later, a superficial burning or shooting pain and/or tingling (pins and needless) can appear in a buttock, back of the thigh and calf, and occasionally in the calf, foot or toes, usually only on one side [5,19,40,41,43]. The leg pain, known as sciatica, can be mild or severe and can occur with or without lower back pain; usually, the leg pain is more severe than back pain [43,81]. The pain location depends on which disc is affected (see Chart 2 below).
- In advanced cases, numbness and leg weakness can develop .
- Pain can be triggered by coughing, sneezing, bending or other waist movements, lifting heavy loads, sitting, vibration (driving), prolonged standing, lifting a leg forward and intense running [5,10].
- Pain can be relieved by lying on a side with bent hips and knees (fetal position) or with a pillow under the knees, by frequently changing position, walking or slow running [10,43].
- You may have a “cold foot symptoms” with a cold, pale and numb foot .
Chart 2. Symptoms of Pinched Nerves in the Lower Back
Pain and paresthesia distribution (Dermatome)
Affected muscle functions
|L1||L1-L2||Lower back, hip, groin (inguinal region)|
|L2||L2-L3||Lower back, hip, upper front and inner mid thigh||Raising the leg forward|
|L3||L3-L4||Lower back, hip, a part of the front and inner thigh, medial part of the knee and calf||Raising the leg forward|
|L4||L4-L5||Lower back, outer thigh, front of the knee, inner lower leg, inner ankle, medial part of the foot, big toe||Raising the leg forward or backward|
|L5||L5-S1||Lower back, upper buttocks, outer thigh, knee, lower leg and heel, upper part of the foot, 2nd to 4th toe and the related part of the sole||Raising the leg backward and knee flexion|
|S1||S1-S2||Buttocks, back of the thigh, outer lower leg, outer ankle, outer part of the foot, 5th toe||Raising the leg backward and knee flexion|
|S2||S2-S3||Buttocks, genitalia (penis, scrotum), back of the thigh and calf, the inner bottom part of the heel||Spreading the toes and flexion the foot downward|
|S3, S4, S5||from S3-S4 to S5-Coc1||Around the anus, genitalia (penis and scrotum, vulva) and the area between the anus and genitalia (perineum)||(S3) Spreading the toes|
|Coc 1||Coc1-Coc2||Coccyx (tailbone)|
Chart 2 sources: [18, 19,20,22,23,24]. NOTE: there may be some overlapping between dermatomes. Sometimes, radicular pain may not follow dermatomes at all [30,33].
Physical Examination: Provocative Tests and Signs
Palpation may reveal tenderness or trigger points near the lumbar spine.
Straight leg raise (Lazarevic test). You lie on the back and a doctor starts to raise your extended leg. If the leg elevation between 30 ° and 70 ° triggers pain that radiates from your lower back to at least below your knee, you may have lumbar radiculopathy, especially at L5 or S1 [5,38,59]. The positive test (pain) does not confirm radiculopathy, but negative test (no pain) pretty much excludes it .
Lasègue test is the same as straight-leg test, only with additional forced flexion of the foot during leg raise .
In a crossed straight leg raise test a doctor raises your unaffected leg; the pain that appears in your affected leg further speaks for lumbar radiculopathy .
Pelvic rocking. A doctor flexes your hip and moves your leg in various directions ; if this triggers pain in your lower back or buttock, it’s likely you have lumbar radiculopathy .
Neurological examination (sensitivity, muscle strength and reflexes in the leg) is usually normal .
Valsalva maneuver (exhaling against closed mouth and nose) may trigger pain in the lower back .
Complications of Herniated Discs in the Lower Back
Spondylolisthesis–a forward displacement of vertebra–caused by an injury or severe disc degeneration can cause a palpable indent in the lower back spine.
A large disc herniation can result in a stenosis of the spinal canal with a compression damage to the spinal cord–myelopathy–with pain, tingling, numbness and heaviness in the hands and feet and, rarely, with bladder and bowel incontinence and erectile dysfunction [45,63].
A large disc herniation in the lumbar spine can press upon several lumbar nerve roots at the same time and cause the cauda equina syndrome, which is a medical urgency with bladder and bowel incontinence, bilateral numbness in the buttocks and inner thighs area (saddle pattern) and pain in the back of the leg .
Differential Diagnosis for Lumbar Radiculopathy
Conditions that can cause symptoms similar to lumbar radiculopathy [2,6]:
- Psychological stress (pain in the lower back, but not in a leg)
- Muscle strain or tendon/ligament injury 
- Shin splints (pain on the medial side of the lower leg triggered by running)
- Ankylosing spondylitis (stiffness and pain in the lower back and buttocks, worse in the morning, in young men) 
- Psoriatic spondylitis (inflammation of the joints in fingers and toes, low back pain, with/out skin psoriasis)
- Sacroiliac joint dysfunction (pelvic pain) 
- Hip disorders (pain in the hip, groin and front of the thigh)
- Piriformis syndrome 
- Reactive arthritis in males after urinary tract infection or sexually transmitted disease (pain in the lower back, knee, ankle and foot, inflammation of the eyes)
- Stress fracture of the 5th or 4th lumbar vertebra (spondylolysis) common in young athletes (sharp pain in the lower back at the waistline) 
- Compression fracture of the vertebra due to osteoporosis or bone cancer (sudden, disabling, knife-like pain in the middle or lower back) 
- Kidney disorders: stones (sudden, extreme pain), infection or pyelonephritis (tenderness in one or both flanks, fever, cloudy urine)
Treatment Options for Lumbar Radiculopathy
There seems to be insufficient evidence of any treatment, including analgesics, physical therapy, spinal manipulation, steroid injections and surgery, that would result in better symptom relief 1-2 years after the onset of symptoms than no specific treatment at all [81,82].
1. Partial Rest and Home Remedies
After acute disc herniation with severe pain, bed rest from few hours to 7 days may provide some pain relief but does not result in faster recovery, so continuing with mild physical activity, like household work and walking, as soon as possible is recommended [2,81].
Moist heat pads and ice packs for 20 minutes several times a day can help relieve acute pain.
Back school — a small group education about spinal anatomy, herniated discs, proper lifting, improving sitting or sleeping position, etc. is recommended [35,81].
Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, or stronger analgesics can help relieve pain.
- Intradiscal Electrothermal Therapy (IDET) and Radiofrequency Posterior Annuloplasty (RPA) involve a placement of an electrode into the disc .
- Inversion tables are popular, but there seems to be a lack of studies of their effectiveness. In one small 2012 study, fewer participants who were using inversion table needed surgery than those who were not .
- Physical therapy
- Stretching exercises (walking over flat ground, pool therapy, swimming, hamstring stretching routine, psoas major stretch and abdominal bracing may not be more effective than relative rest and ice packs [14,19,81,82].
- Massage may help relax tight spinal muscles [8,35].
- Lumbar traction [35,81,82]
- Wearing back braces may weaken back muscles and make the problem worse [35,83].
- Spinal manipulation by a chiropractor . Spinal manipulation in an individual with a large herniation may worsen the symptoms .
- Transcutaneous electrical nerve stimulation (TENS) can provide some relief immediately after the procedure but less likely a long-term relief .
- There seems to be no evidence of the effectiveness of acupuncture [81,82].
- Trigger point injections (steroids and local anesthetics) into the muscle knots may help relieve pain due to muscle spasms [19,81].
- Epidural steroid injections (cortisone or methylprednisolone with a local anesthetic) may provide pain relief lasting for few days or up to several months according to some sources [7,15,35,60] but not to others [81,82].
Surgical treatment of lumbar radiculopathy can provide fast pain relief but 1-2 years after the onset of pain there seems to be no significant difference between surgery and conservative treatment . In about 20% of individuals, surgery does not relieve pain .
Recovery time. You can expect to get out of the hospital in about 2 days and get back to work in about a week after a low back surgery. Often, you can expect to be pain-free in about 6 weeks after surgery; you may still feel some tingling at 3 months and some numbness for up to about a year .
Living with a Herniated Disc
- Avoid smoking and excessive alcohol drinking.
- If overweight, lose weight.
- Learn to lift objects properly.
- Improve bad posture.
- References: [8,11,60]
Prognosis and Recovery Time
Often, the pain from a herniated disc goes away completely or becomes less severe in few weeks or several months just with a conservative treatment (medications, physiotherapy) or without any specific treatment at all [25,26,81]. The herniated part of the disc can be reabsorbed (disappears) in 1-2 years on its own [31,44,59]. A disc that was once herniated and then healed is more vulnerable for subsequent herniations.
Prevention – Proper Lifting
The proper lifting of heavy objects can help prevent low back injuries including herniated discs. Keep your feet apart, with one foot behind the load and the other in front.
Picture 5. Proper lifting technique:
feet apart, straight back, lifting vertically
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