Intervertebral disc prolapse - symptoms and therapy
The herniated disc, or intervertebral disc prolapse, is a well-known spinal disease that has very different causes and is often associated with sudden back pain. On the other hand, it is less known that a herniated disc can also be symptom-free or that other complaints can arise due to a torn and distended disc. The symptoms and also the therapy options are largely determined by the extent, location and direction of a herniated disc.
A brief overview
Often people with back pain or lower back pain think of a herniated disc. However, a herniated disc is rarely responsible for these symptoms. The following section briefly summarizes what happens in a herniated disc, which symptoms actually indicate a herniated disc and which treatments are considered today. The further article describes the clinical picture comprehensively and provides additional important information for those affected and interested.
Disc herniation: what is it?
In the event of a herniated disc, the entire fibrous ring of an intervertebral disc tears in whole or in part, causing the otherwise centrally positioned jelly core to shift and penetrate outward into the spinal canal. This can result in pinched nerves and pressure on the spinal cord, which can have very different effects.
What are the typical signs?
Disc herniations can be completely symptom-free or can cause (severe) pain and other symptoms. The location, direction and extent of the incident are decisive for the symptoms. Accordingly, a distinction is made between the following typical complaints, which can manifest themselves to different degrees:
- Symptoms of an incident in the lumbar spine: Acute or chronic pain in the lower back, which radiates to the buttocks and legs, sciatica pain, posture and restricted movement, sensation disorders in the limbs or legs (tingling, numbness) and symptoms of paralysis.
- Symptoms of an incident in the cervical spine: Neck pain that radiates into the arms / hands and the back of the head, gentle posture (crooked head posture), sensory disorders and paralysis.
- Symptoms of an incident in the thoracic spine: Back pain in the affected spine section, which usually does not radiate and does not cause other disorders.
- Symptoms of an acute emergency: Cross-sectional syndrome (especially Cauda-Equina syndrome) with paralysis (legs), sensation disorders and numbness in the area of the anus, genitals and inner thighs (ankle anesthesia), organ function disorders (rectum, bladder, genitals) with consequences of impotence as well as urinary and faecal incontinence.
Which therapies help?
A herniated disc does not necessarily require special therapy without complaints. In contrast, emergency situations always require immediate surgical intervention to prevent irreversible consequences. However, surgery can also be considered in other long or serious cases.
Most herniated discs, with mild to moderate complaints, are treated with conservative methods. Movement therapies and manual procedures are primarily used. Targeted back training, back training and special handles for muscle relaxation are important methods here.
Furthermore, the pain is often treated with heat therapies and especially in the early stages with appropriate pain relievers. To support the healing process and for prevention, various naturopathic treatments also offer possibilities to counteract the causes and symptoms.
The herniated disc is also known under the synonyms intervertebral disc prolapse (derived from the Latin "prolapsus nuclei pulposi"), disc prolapse or disc hernia. This is a disease of the spine caused by damage to the intervertebral disc that allows parts of the intervertebral disc to escape into the spinal canal. Here there are nerve roots and the spinal cord and the result is often a pinched nerve or a narrowed spinal cord. This in turn can trigger various types of pain. Depending on the situation, one speaks of a herniated disc of the lumbar spine (LWS), cervical spine (HWS) or thoracic spine (BWS).
Function of the intervertebral discs
There are a total of 23 intervertebral discs between the individual vertebrae of the spine. Only between the top two cervical vertebrae and in the area of the intermingled vertebrae of the sacrum and coccyx are none. The intervertebral discs perform an important buffer function. As so-called shock absorbers between the vertebrae, they ensure an even pressure distribution and thus protect against excessive pressure and abrasion.
As a flexible connection of the vertebrae, the intervertebral discs not only ensure the stability of the spine, but also give it the necessary elasticity. The spine would not be movable without intervertebral discs. The intervertebral discs adapt to the different positions of the spine and ensure a literally smooth movement.
Structure of an intervertebral disc
The intervertebral discs consist of two parts of different tissue. The outer part is formed by the fibrous ring (annulus fibrosus), which consists of many layers of connective tissue fibers. On the inside, these fibers form the fibrous cartilage, on the outside they are firmly attached to the periosteum of the two surrounding vertebrae. This ensures a firm and resilient connection between the individual vertebrae. The intervertebral disc is also held in this position.
In the middle is a jelly nucleus (nucleus pulposus), which consists of cell-poor tissue with a high water content (up to 85 percent). The nucleus forms a kind of water or gel cushion, which balances and absorbs the pressure on the spine. The position of the gelatinous nucleus changes as the spine moves. When bending over, it shifts backwards, for example, because the front sides of the vertebrae are pressed together and thus exert one-sided pressure on the intervertebral disc. The fiber ring surrounds the gelatinous core with adjacent longitudinal bands (front and rear longitudinal band) and thus functions as a protective outer shell that withstands strong pressure and tensile forces.
Metabolism of an intervertebral disc
The blood vessels in the intervertebral discs initially close in the growth phase, so that the intervertebral discs have to be supplied by the surrounding tissue. This happens through the diffusion of nutrients, which works through movement. The spinal disc absorbs fresh nutrient fluid like a kind of sponge and releases the used fluid under stress. A lack of exercise, on the other hand, leads to disorders in the metabolism. For example, permanent one-sided loads, such as sitting for long periods, have the same unfavorable effects as too long underloads, for example due to longer periods of bed rest.
What is a herniated disc?
Various causes can cause cracks to form in the fiber ring. Under pressure, the gelatin core penetrates these cracks and pushes them apart. The intervertebral disc is deformed by this process. If the fiber ring is torn in whole or in part, the nucleus completely penetrates it and enters the spinal canal outwards. This is then called a herniated disc (prolapse).
If the leaked tissue is still connected to the intervertebral disc, one speaks in specialist circles of an extrusion. On the other hand, if there is no longer a connection, this is called a sequester. A distinction is also made between different forms of an intervertebral disc prolapse based on the respective direction of the escaped gelatinous nucleus. Most often, a mediolateral incident is diagnosed, in which the intervertebral disc moves in the middle backwards and to one side.
To be distinguished from an incident as a kind of preliminary stage is the incomplete prolapse, also known as protrusion. The outer shell of the fiber ring remains intact and the gelatin core does not penetrate to the outside.
Herniated discs occur more frequently from the age of 30. The reason for this is the increasing signs of wear with age, which are the most common cause. Overall, about twice as many men as women are affected.
Many people wrongly assume that back pain or lower back pain always occurs in a herniated disc. This pain can occur, but not every herniated disc causes (this) discomfort. An incident can go unnoticed for a long time and can only be diagnosed by chance. In principle, the location, direction, and extent of the spinal disc that emerges determine whether and which nerve structures are damaged and what symptoms can result. The most common is a lumbar disc herniation, with the complaints coming from the lumbar region. Sometimes there is also a cervical herniated disc in the area of the cervical vertebrae (cervical spine), only very rarely is it a thoracic incident of the thoracic vertebrae area (cervical spine). In a few cases, a herniated disc can also lead to an acute emergency situation.
Symptoms of an incident in the lumbar spine
The most common occurrence of intervertebral disc damage is between the fourth and fifth lumbar vertebrae (LWK 4 / LWK 5) or between the fifth lumbar and first coccygeal vertebrae (LWK 5 / SWK 1). In this area, there is usually the greatest stress on the vertebrae and intervertebral discs, which increases the risk at this point.
If a spinal disc presses against nerves in the area of the lumbar spine, (severe) pain in the lower back is a typical consequence. The pain can radiate to the buttocks and legs and even cause sensation disorders (tingling and numbness). In very severe cases, symptoms of paralysis can even occur.
The pain usually occurs suddenly when moving, for example when lifting heavy objects or when bending over. Most of the time, those affected take a gentle posture, which hardens the protective muscles on the spine and creates a feeling of stiffness and restricted movement. Depending on the incident, the pain can be acute or become chronic. The duration of the symptoms that appear depends heavily on the extent and on the chosen therapy and its success.
It can happen that the spinal disc that has emerged in the lower lumbar spine has pinched the sciatic nerve running here, causing radiating back pain. These are also known as sciatica or sciatica. Often, coughing, sneezing and exercise exacerbate the pain. This acute pain is popularly known as lumbago. A typical lumbago rarely occurs due to a herniated disc, in most cases other causes are responsible.
Symptoms of an incident in the cervical spine
A herniated disc in the cervical spine is much less common than in the lumbar region. Most often the incidents manifest themselves between the fifth and sixth or the sixth and seventh cervical vertebrae (HWK 5/6 or HWK 6/7). The pain caused mainly affects the neck, but can also radiate into the arms and hands or in the back of the head and cause sensation disorders and paralysis. One consequence is often a gentle posture, which leads to a crooked head posture.
Symptoms of an incident in the thoracic spine
In this extremely rare variant, the possible symptoms are usually limited to back pain in the affected spine section of the chest area. As a rule, there is no radiating pain and disorders in other areas.
Symptoms of an acute emergency
If it is a very large herniated disc, not only can nerve strands constrict in the spinal canal, but there can also be pressure on the spinal cord. This pressure can pinch the spinal cord in the corresponding vertebral area in such a way that a so-called cross-sectional syndrome can occur. In addition to paralysis and sensory disorders, organ function disorders also occur.
It is mostly Cauda-Equina syndrome, which is caused by bruises in the lower spinal cord. Cauda equina is the term used to describe nerve roots arranged like a horse's tail, which extend from the first lumbar vertebra to the sacrum. If a herniated disc narrows this structure, not only pain in the lumbar region but also numbness in the area of the anus, genitals and inner thighs can occur (breech anesthesia). Paralysis also occurs occasionally in other areas of the legs. These symptoms are usually accompanied by impotence, urinary and bowel incontinence. These are clear signs of an emergency that requires immediate medical attention and, as a rule, immediate surgical intervention.
The most common cause of herniated discs is general signs of wear. The intervertebral discs lose their function as shock absorbers in old age and loads can no longer be distributed and cushioned as well. In the course of every normal aging process, the fluid in the intervertebral discs gradually reduces. This makes them brittle and less elastic, which can lead to tears in the intervertebral disc and which in turn favors the appearance of protrusions and incidents.
In addition to the aging process, other risk factors promote the occurrence of complaints on the spine or on the intervertebral disc. These factors include overweight (obesity), lack of exercise, heavy physical work and poor posture, or excessive, one-sided or incorrect stress. Incorrect lifting of heavy objects often leads to excessive pressure on some intervertebral discs. Or insufficiently trained back and abdominal muscles lead to a reduced stability of the spine and thus to a lower protective function for the intervertebral discs. Too little exercise leads to reduced metabolic activity and an undersupply in the intervertebral discs, which results in a correspondingly lower resilience.
Usually, several factors cause damage to the intervertebral disc. Together, these already have a negative impact before the actual incident occurs. There are very few herniated discs due to an accident or serious injury.
If the complaints are so severe that those affected seek medical advice, the symptoms described above are first asked in the detailed patient survey (anamnesis). This is followed by a thorough physical and neurological examination. It is examined whether and which nerve damage causes the symptoms. The approximate position of a possible herniated disc can usually be determined with the help of these examinations. Reflexes, mobility and (pain) sensation and possibly also the nerve conduction speed are tested thoroughly. Muscle activity can also be measured using electromyography (EMG) or electroneurography (ENG). In addition to a herniated disc, this finding can also indicate other possible nerve diseases (e.g. polyneuropathy) that result in similar symptoms.
In more complicated cases or in the case of serious and long-lasting complaints, imaging diagnostic procedures can be used. This enables herniated discs to be seen in detail and, under certain circumstances, to rule out other causes of the complaints.
With the X-ray method, only the bones (vertebrae) can be visualized and possible movement disorders and signs of wear can be made visible. However, in order to visualize the spinal cord and the nerves, further procedures are required, such as computer tomography (CT) or magnetic resonance imaging (MRI), which is used even more frequently. The images make it possible to determine the exact position and direction of the incident. Nowadays, the invasive method of myelography is rarely used to image nerve roots and possible damage.
However, since imaging diagnostics also carry the risk of a possible misdiagnosis, these procedures are only carried out under certain conditions. They should always be interpreted with a certain degree of caution in order not to come to the wrong conclusions.
If other causes of the symptoms are suspected on the basis of the examinations, further diagnostic procedures are necessary.
A manual diagnosis of the spine can also be used as part of an exact physical examination. This is a diagnostic procedure of manual therapy or osteopathy, which precedes the corresponding therapeutic procedure.
Special hand movements and techniques are used to locate and analyze movement and functional disorders on the spine. The finding serves as the basis for possible manual therapy. A well-known method is, for example, mechanical diagnostics and therapy (McKenzie therapy).
The so-called Lasègue test, in which the patient's leg is raised gradually while lying on its back, causes the sciatic nerve to stretch at different angles. If pain occurs, this can indicate a herniated disc, but also other causes.
If there is already a diagnosis and localization of a herniated disc using MRI or CT, manual diagnosis often examines the segments of the spine below and above it, since disorders at another point can also lead to overloading and prolapse. In the following treatment, these movement restrictions or other (functional) disorders should also be treated if possible.
Nowadays, so-called conservative therapy is (initially) carried out for most herniated discs. Acute pain relief and muscle building come first. The symptoms should decrease significantly during the first one to three months. If this is not the case or if it is a serious incident from the outset, surgical intervention may be necessary.
The pain relief is extremely important so that movements and the posture of those affected normalize again and the movement therapy described below is even possible. Most often, especially in the early stages, pain and anti-inflammatory drugs are prescribed, which also have a decongestant effect. Non-steroidal anti-inflammatory drugs (such as ibuprofen) are primarily used. The more controversial COX-2 inhibitors or cortisone are used less often. In the case of very severe pain, local anesthetics or opiates can also be used for pain treatment. If the pain persists for a particularly long time, the administration of antidepressants may also be considered. If severe muscle tension is associated with a herniated disc, occasional muscle relaxants can also be administered in order to remedy the resulting pain and movement restrictions in anticipation of further therapy.
But even without the administration of medication, it is possible to relieve the pain that occurs. Relaxation methods, massage or heat therapy can alleviate muscle tension and related complaints. In addition, those affected can rest on a step bed during breaks or at night, with the legs raised at a right angle to the knee and hip joint. This helps to relieve affected nerves.
Contrary to some expectations, immobilization of the spine is advised only in very rare cases. If this is the case, you want to enable short-term relief, especially in the case of very severe pain, in order to then start a longer-term therapy.
Movement means a change between loading and unloading the intervertebral discs and thus promotes their necessary metabolism. In addition, certain physical exertion strengthens muscles in the trunk area, which are particularly important for the stability and protection of the spine. Generally, regular, light to moderate exercise is recommended to those affected. This affects everyday movements, but also targeted exercises.
With every form of movement, the correct and healthy implementation is essential to achieve a positive result. Physiotherapy is usually used to train healthy and pain-free movements that can be used in everyday life.
In addition, exercises to strengthen the back and abdominal muscles are helpful, which support the healing process in the acute state, but also prevent possible long-term complaints of the spine and intervertebral discs. These exercises are often taught as part of a back school.
In principle, there is nothing to prevent sporting activity even after a herniated disc. However, some sports are stressful on the back or intervertebral discs, such as tennis, squash, weightlifting, football or volleyball. It can be advisable to do without certain sports and, for example, to practice back-friendly activities such as cycling, backstroke, walking or Pilates exercises. If stressful sports are nevertheless carried out, compensatory training is very important.
If there are prerequisites that make a surgical intervention necessary, this is usually discussed extensively with those affected. Possible circumstances and symptoms that make surgery necessary include symptoms of cross-sectional syndrome or Cauda Equina syndrome. With severe or increasing paralysis and dysfunction of the bladder and rectum, an immediate intervention is usually necessary to prevent irreversible death of nerve roots.
But surgery can also be considered in the case of persistent symptoms without treatment success of the conservative measures over a longer period (about three months).
The current standard procedure is microsurgical discectomy. With the help of an operating microscope and the smallest instruments, the part of the gelatinous nucleus and parts of the intervertebral discs (nucleotomy) are removed to relieve the pinched nerves. Only a small skin incision is necessary to carry out the operation, which makes this type of intervention one of the minimally invasive procedures.
As with any operation, there are potential risks. Complications are extremely rare, but there is a risk that a nerve will be injured during the procedure. This can result in sensation and movement disorders in the legs, functional disorders of the bladder and intestines and sexual disorders. It is precisely these complaints that the surgery was intended to remedy or prevent. Another possible complication is bacterial inflammation of the disc (spondylodiscitis), which is usually prevented with an antibiotic. It is also possible that similar symptoms will not reappear until weeks or even months after the procedure. A check-up is usually done half a year to a year after treatment.
The hospital stay immediately after the procedure usually lasts only a few days. However, inpatient or outpatient rehabilitation (in short: rehab) usually follows, which largely consists of the previously described measures of physiotherapy.
In addition to microsurgical discectomy, there are also other surgical methods that are used under certain conditions. In the case of uncomplicated incidents or bulging of the intervertebral disc, for example, this includes the percutaneous endoscopic method. In the case of complicated cases, however, the previously more frequently used method of open intervertebral disc surgery can also be an option. Each technology has its own advantages and disadvantages and harbors corresponding risks.
In the case of a herniated disc, movement therapy and targeted back training (physiotherapy) are essential. These measures not only have a positive effect on healing, but renewed spinal damage is also prevented as much as possible if it is carried out permanently. Unfortunately, drug pain therapy can often not be dispensed with, especially in the early days.
Nevertheless, methods from naturopathy can support, alleviate the symptoms and improve the condition of the spine. This primarily includes manual therapy under the holistic approach. Especially methods of osteopathy offer good opportunities to treat a herniated disc in the acute phase and to prevent new complaints. This includes, for example, the fascia distortion model (FDM).
Cupping can also offer a supportive measure for muscle relaxation. Special cupping glasses are applied to the skin in the painful areas and also to distant parts of the body under a created vacuum. In addition to other effects, this technique can also relieve tension in the muscles.
In order to reduce the risk of further herniated discs and back ailments, other naturopathic treatments also offer corresponding options for prevention. In this context, remedies from complex homeopathy or dietary supplements can contribute to cartilage regeneration or counteract collagen degeneration. A relatively high proportion of collagen in a healthy intervertebral disc structure ensures its stability and flexibility. If the amount of collagen decreases (also in the natural aging process), the intervertebral discs become susceptible to damage.
Silicon with glucosamine and chondroitin are often administered to supplement this. Complex homeopathics usually also contain Calcium carbonicum. This remedy is often used in homeopathy for back problems, such as a lumbago. Other homeopathic medicines used for back pain and especially sciatica pain include:
- Nux vomica,
- Rhus toxicodendron.
If one looks at the possible causes of the complaints in the back and the occurrence of a herniated disc from a naturopathic point of view, psychosomatic aspects are also taken into account. If the psyche plays a role in the illness, such as mental overload or an internal “bad posture”, psychotherapeutic measures, techniques for mental relaxation or the medicinal plant masterwort (Peucedanum ostruthium) can be used.
In addition to exercise and an adequate hydration, a balanced diet also has a positive effect on physical and mental health. If one also considers acidification of the body or chronic inflammatory bowel diseases as possible causes of a herniated disc, nutrition is of particular importance in therapy and for prevention. In this context, those affected are advised to eat anti-inflammatory and basic foods. Base-forming foods also have a positive effect on cartilage build-up. If sufferers have (permanent) bowel problems, regular natural bowel cleansing and bowel rehabilitation can help.
Current state of research
In recent years, the idea of closing a tear in the intervertebral disc from the inside has become a real therapy option for those affected. The Spanish company NEOS Surgery turned to the German Institute for Textile and Fiber Research (DITF) with the innovative idea of developing a prototype for a functional closure. The result is a new kind of intervertebral disc closure in the form of a textile implant. After the ongoing test phase, the implant is scheduled to come onto the market in 2019. In 2017, this development received the EUREKA innovation award for the intervertebral disc implant in the category "Innovators for tomorrow".
The development of a new therapy for chronic pain can also help to alleviate pain in the future, which is caused, among other things, by herniated discs. The so-called SFMS therapy (Small Fiber Matrix Stimulation) is a specially developed pain band via which targeted electronic impulses are sent. This leads to a proven, permanent reduction in pain, which is why many health insurance companies are already covering the costs of this therapeutic approach. (tf, cs; updated on October 19, 2018)
Author and source information
This text corresponds to the requirements of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
Dr. rer. nat. Corinna Schultheis
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ICD-Codes für diese Krankheit:M50, M51ICD-Codes sind international gültige Verschlüsselungen für medizinische Diagnosen. You can find yourself e.g. in doctor's letters or on disability certificates.