Lumbar disc herniation: When is it best to wait and see, and when is surgery necessary?

The intervertebral discs are situated between the vertebral bodies. They act as elastic cushions and enable movement of the spine. They consist of an outer fibrous ring and a softer centre. If the fibrous ring tears and disc tissue protrudes outwards, it can press on a nerve root.

In the case of a herniated disc in the lumbar spine, the nerve irritation often affects the nerves that run down into the leg. The pain can therefore radiate from the lower back, through the buttocks, and down into the thigh, lower leg or foot. Depending on which nerve root is affected, certain areas of skin may become numb or individual muscles may lose strength.

A herniated disc in the cervical spine typically causes symptoms in the neck, shoulder area and arm. Tingling or numbness may extend as far as individual fingers. In cases of more severe compression, hand strength or fine motor skills may also be impaired.

Not every disc change visible on an MRI scan causes symptoms. The imaging findings are therefore not sufficient on their own to decide on a course of treatment. The key factor is whether the symptoms and the examination findings correspond to the visible changes.

Not every herniated disc requires surgery. If there are no significant neurological deficits, conservative treatment is often tried first. This includes pain management, exercise and, where appropriate, physiotherapy. Prolonged bed rest is no longer recommended these days, as prolonged inactivity can weaken the muscles and make it more difficult to return to everyday life.

The body itself can also contribute to recovery. Protruding disc tissue can be partially broken down by the immune system. This can reduce the pressure on the affected nerve root over time. In many patients, symptoms therefore improve within a matter of weeks.

There are symptoms where one should not simply wait and see. These include newly occurring or worsening symptoms of paralysis. Problems with urination or bowel movements may also indicate significant nerve compression. Numbness in the so-called ‘riding breeches’ area should be taken particularly seriously. This refers to the region around the anus and genitals, as well as the inner thighs. If such symptoms occur in connection with a slipped disc, they may be caused by a condition known as cauda equina syndrome.

In this condition, the nerve fibres in the lower part of the spinal canal are severely compressed. This is a medical emergency and must be investigated immediately. In such cases, urgent surgery may be required to prevent permanent nerve damage as far as possible.

If surgery becomes necessary, the procedure can often be carried out via a small incision, provided the conditions are suitable. In microsurgical procedures, the surgical site is visualised under optical magnification. The main aim is to remove the disc tissue that is compressing the affected nerve. Depending on the location and size of the herniation, endoscopic procedures may also be considered. In these procedures, an endoscope is inserted into the surgical area via a small incision. The technique used depends, amongst other things, on the position of the herniation and the anatomical conditions.

The aim of the operation is to relieve pressure on the nerve root. Surgery can lead to a rapid improvement in radiating symptoms, particularly in cases of severe nerve compression. However, it is not without risks and is therefore not automatically the best solution for every herniated disc. When planning surgery, the symptoms, the neurological examination and the imaging results should therefore be considered together.

Not every procedure on the intervertebral disc has the same objective. In selected patients with a severely damaged disc, for example, a disc prosthesis may be an option in order to preserve the mobility of the affected section of the spine as much as possible.

Another option is spinal fusion, medically known as spondylodesis. This involves permanently fusing adjacent vertebrae together. This may be necessary in certain forms of spinal instability or in cases of severe degenerative changes.

Following disc surgery, mobilisation usually begins at an early stage. How quickly patients can return to work, take part in sport or carry out physically demanding activities depends on the specific procedure and the healing process.

Physiotherapy can help to rebuild mobility and muscle strength. The focus is often on exercises for the back, abdomen and legs. The aim is to gradually reintroduce the body to normal levels of physical activity.

Back-friendly behaviour also plays a role in everyday life. This includes, for example, regular exercise and ensuring the spine is subjected to as balanced a load as possible. Heavy lifting should, of course, be avoided following an operation. If severe radiating pain, numbness or loss of strength reoccur after the procedure, the cause should be investigated by a doctor.

A herniated disc does not automatically require surgery. If there are no neurological deficits and the symptoms improve, conservative treatment may be sufficient. If, on the other hand, paralysis, bladder or bowel dysfunction, or numbness in the ‘saddle’ area occurs, immediate medical assessment is required. The appropriate treatment always depends on the individual findings.