Lumbar disc herniation

The most important thing first

• Not every lumbar disc herniation requires surgery. In many cases, pain stabilizes within 6-12 weeks with conservative therapy.
• Warning signs (emergency): increasing paralysis, bladder or rectal disorders, numbness in the breeches area, fever or severe pain at night when resting - please seek medical advice immediately.
• Imaging (MRI) is useful for persistent radicular complaints, neurological deficits or for surgical planning - not immediately necessary for every acute back pain.
• Exercise, targeted pain therapy and physiotherapy are the cornerstones of treatment. Short-term infiltrations can help in selected cases.
• Surgery is an option for progressive neurological deficits or if severe leg pain persists despite adequate conservative treatment.

Anatomy and what happens during an incident

Intervertebral discs lie between the vertebral bodies and consist of an outer fibrous ring (anulus fibrosus) and a gel-like core (nucleus pulposus). They absorb shock and allow mobility. In the lumbar spine, L4/L5 and L5/S1 are most commonly affected.

• Protrusion: bulging of the fibrous ring, core remains inside - can irritate nerves, but does not have to.
• Prolapse/Sequestration: Tear in the fibrous ring, core parts come out and can compress a nerve root.
• Typical nerves: L5 (foot and big toe lift, sensitivity of the lateral lower leg) and S1 (calf strength, Achilles tendon reflex, sensitivity of the lateral edge of the foot).

Important: MRI findings and complaints must match. Even a “big” incident can cause few symptoms – and vice versa.

Symptoms: How do you recognize a lumbar disc herniation?

• Back pain, often sudden (lumbago) or after exertion.
• Radiating leg pain along a nerve (sciatica): burning, electrifying, increased when coughing/sneezing/straining.
• Sensory disturbances: tingling, numbness – e.g. B. Big toe (L5) or outer edge of the foot (S1).
• Reduced strength: problems with heel or toe walking.
• Protective posture, limited mobility of the lumbar spine.

Red flags that should be clarified immediately: new bladder or rectal disorders, breeches anesthesia, rapidly increasing paralysis, severe unclear general symptoms (fever, weight loss), or pronounced pain at night when resting.

Causes and risk factors

A herniated disc is usually the result of natural degeneration: the water content of the core decreases, the fibrous ring becomes more brittle and cracks can occur. The stresses of everyday life have an impact on this - often an inconspicuous movement is enough to trigger it.

• Individual predisposition, aging processes of the intervertebral discs
• Sitting for long periods of time, lack of core stability, one-sided strain
• Lifting and carrying in an awkward posture
• Smoking (worse disc nutrition)
• Obesity and low physical activity
• Rare: accidents, severe trauma or inflammatory/infectious processes

Diagnostics: This is how we proceed

It starts with a careful anamnesis and a physical-neurological examination. What is important are pain progression, radiation, intensification (coughing/pressing), sensory disturbances and strength tests.

• Clinical tests: Lasègue (SLR) to check for stretch pain of the sciatic nerve; Reflexes (patella/Achilles tendon), strength and sensitivity testing.
• MRI of the lumbar spine: recommended for red flags, persistent radicular pain > 4-6 weeks or before a planned intervention/surgery.
• CT as an alternative if MRI is not possible; X-ray if instability/bone changes are suspected.
• Laboratory only if inflammation/infection is suspected; electrophysiological tests in selected cases.

We interpret findings in connection with the symptoms. “Accidental findings” are common and do not justify invasive therapy without appropriate symptoms.

Differentiation: What can look similar?

• Lumbar myofascial pain syndrome: muscular tension and fascia problems, often without nerve root signs.
• SIJ blockade: deep, lateral lower back pain radiating to the buttocks, often without neurological deficits.
• Spinal canal stenosis of the lumbar spine: load-dependent leg pain/tingling, typically improvement when sitting/leaning forward.
• Spondylolisthesis (vertebral slipping): Back pain with/without radicular complaints.
• Hip joint pathology: groin pain, limitation of hip mobility.
• Rare: tumors, infections, inflammatory rheumatic diseases.

Conservative therapy: step by step

The aim is to reduce pain, calm inflammation, relieve pressure on the nerve root and enable a quick return to activity. The majority of patients benefit from a structured, step-by-step approach.

Accompanying procedures such as acupuncture or manual therapy techniques can alleviate symptoms, but should be supplemented by active therapy (exercises, stability). A rigid lumbar bandage is usually not necessary in everyday life and is only used for a short time, if at all.

Course: For many sufferers, the pain decreases in 6-12 weeks. Regular re-evaluation (pain, sensitivity, strength) is important. If the situation deteriorates or new failures occur, the procedure must be adjusted and, if necessary, further clarified at an early stage.

When does an operation make sense?

Surgery is considered if conservative measures do not bring sufficient improvement despite adequate duration and intensity or if relevant neurological deficits increase. In the case of cauda equina syndrome (bladder/rectal disorder, breeches anesthesia), rapid surgical relief is urgently indicated.

• Relative indication for surgery: persistent, severe radicular pain with correlating MRI findings and relevant suffering after 6–12 weeks of structured conservative treatment.
• Absolute indication for surgery: progressive paresis or cauda equina signs.

Common procedures include microsurgical discectomy or endoscopic techniques. The aim is to relieve pressure on the nerve root by removing the prolapsed material. Every operation carries risks (e.g. bleeding, infection, scarring, recurrence). A careful risk-benefit assessment and consideration of your individual goals are the priority.

After surgery, early functional mobilization, pain control and a gradual increase in load are important. A structured rehabilitation program supports the return to work and sport.

Everyday life, self-help and exercises

• Relieving position: short-term step positioning for acute pain, otherwise frequent position changes.
• Exercise: daily, pain-adapted activity (walking, light cycling). Avoid sitting for long periods of time.
• Core stability: regular exercises for abdominal, back and hip muscles; initially under physiotherapist guidance.
• Ergonomics: upright seat height, lumbar support, working at a hip-knee angle of approx. 90 degrees, screen at eye level.
• Lifting/carrying: close to the load, using the legs, building up core tension; Avoid rotational movements under load.
• Sleep: sideways with a pillow between the knees or back-friendly with the knees slightly elevated.

Please carry out exercises adapted to the pain and increase slowly. If new failures occur, increasing numbness or a massive increase in pain, stop and seek medical advice.

Prevention: How to support your lumbar spine

• Regular strength training for the core and hips, 2-3 times per week.
• Daily exercise breaks while sitting, ideally every 30-45 minutes.
• Quitting smoking and eating a balanced diet for tissue health.
• Weight management to relieve pressure on the lumbar spine.
• Check workplace ergonomics: chair, table height, monitor, telephony with headset.
• Everyday routine with short mobilization exercises (e.g. hip flexor stretch, pelvic tilt).

Course and prognosis

The natural tendency of many herniated discs is favorable: symptoms often subside within weeks. The body partially breaks down prolapsed tissue and nerve irritation decreases. A small proportion develop long-lasting pain - a structured, multimodal approach and, if necessary, an intervention or operation according to a clear indication can help.

Relapses are possible. A consistently built muscle corset, ergonomic habits and early countermeasures in the event of new symptoms reduce the risk.

When should you see a doctor?

• Acute, severe leg pain with numbness or new muscle weakness.
• Bladder or rectal disorders, numbness in the genital/breeches area (emergency!).
• Pain persists despite self-medication for 2-4 weeks.
• Recurring episodes that significantly affect everyday life or work.
• Unexplained nighttime pain, fever, general fatigue.

We would be happy to support you in our practice in Hamburg, Dorotheenstraße 48, 22301 Hamburg. You can easily request appointments online or by email.