The symptoms of an intervertebral hernia depend on the location of the hernia, as well as its size. If the herniated disc does not put pressure on the spinal nerves, then the symptoms of the herniated disc may only be back pain or there may be no symptoms at all.
If the hernia puts pressure on the spinal nerves, then among the manifestations there will be weakness, numbness or even paralysis of the limb.
If a herniated disc occurs in the lumbar region, so-called sciatica may occur. This is a condition that occurs when the sciatic nerve is compressed or irritated and is accompanied by pain that stretches from the buttock to the lower leg or even the foot. In this case, there may be a combination of both back pain and leg pain.
If a herniated disc is noted in the upper part of the lumbar spine, then the patient may experience pain along the inner surface of the thigh.
If a disc herniation occurs in the cervical or thoracic spine, pain, numbness, and weakness may occur in the shoulder, arm, or front chest wall.
Causes of pain syndrome
With age, the articular processes of the vertebrae, both medial and lateral, become sources of osteophyte growth.
This leads to a decrease in the size of the intervertebral foramina. The adipose tissue that supports the root on all sides undergoes gradual atrophy, and the arachnoid membrane of the spinal cord, which envelops the root, also changes and gradually atrophies. The nerve roots themselves gradually conduct impulses worse and worse, both the fibers themselves and the ganglia. All this leads to insufficiency of the intervertebral foramen; the root does not become a source of serious pain only if it is at rest. As soon as any load occurs on the spinal column, these resting conditions are disrupted and severe pain occurs.
Osteophytes on x-ray
Numerous physiological studies have shown that a decrease in the height of the intervertebral disc leads to the bringing of adjacent vertebral bodies closer to each other. The corresponding openings between the vertebrae also decrease in size. If there is an extension movement in the lower back, then often the upper vertebra slips a little relative to the lower one. And if this slippage occurs with instability, a reduced size of the intervertebral foramina, then compression of the nerves often occurs, even the process of inflammatory aseptic epiduritis.
In the intervertebral foramina, the roots cease to lie normally, they move upward and become overstretched. When the patient's age approaches 50 years, these symptoms associated with distant pain in the leg appear quite clearly.
By the way, when the root is compressed in the intervertebral foramen, the root is affected at the level of the upper vertebra. So, if a patient has a hernia of L5-S1, then we are talking about damage to the L5 root, and if a hernia occurs at L4-L5, the symptoms correspond to damage to the L4 root.
The most characteristic course of pain is in the presence of foraminal hernias, which do not appear at all with aching pain in the lower back, but with persistent, shooting radicular pain. These pains are especially pronounced when the patient tilts to the painful side, with the slightest shock to the root. This is coughing, sneezing, laughing, straining in the toilet. In this case, a characteristic clinical picture develops with the appearance of pain in the corresponding limb; pain in the leg radiates along its entire length, right up to the big toe.
The most unfavorable situation occurs in the presence of a sequestered hernia, if the sequester moves downward and irritation of the nerves of the cauda equina occurs. The relevant symptoms are described below. In addition to a disc herniation, the root may be compressed by other structures that also need to be taken into account. This:
- compression of the root in the lateral recess of the vertebrae;
- frequent formation of adhesions, including after surgery;
- anatomical features of the structure of the articular processes of the vertebrae, which lead to lengthening of the root, bending it around the root of the vertebral arch;
- compression by the inflamed, thickened ligamentum flavum and osteophytes.
Let's consider how the leg can hurt depending on the location of the hernia.
Hernia of the thoracic and cervical spine
Protrusion of the disc in these areas indicates an incorrect, often sedentary lifestyle of a person. When the cervical vertebrae are displaced, the flow of blood to the brain worsens, this is characterized by loss of consciousness. This condition is due to the fact that the displaced vertebrae affect the passing vertebral artery. The consequences of a vertebral hernia in this part of the spine have their own characteristics and manifest themselves in the form of:
- Headaches, sleep disturbances, vertigo effect
- Back pain, especially in the evening
- Fatigue
- Confusion of thinking and memory impairment
If you do not consult a doctor in a timely manner, the disease can develop into cervical radiculitis, which is very difficult to treat. Complications of the cervical hernia include:
- Apoplexy
- Ischemic stroke
In the initial stage, the hernia does not appear immediately, only sometimes there is a sharp pain that goes away over time. With an advanced hernia, the patient experiences the following symptoms:
- Drowsiness
- Noise in ears
- Nausea
- Double vision
- Dizziness
It is important to know that when moving the head, not only sharp pain can be observed, but also compression of the artery, which can lead to paralysis of any part of the body. The consequences of this disease can be varied: problems arise with urination, weakness appears in the legs. The patient becomes very ill, and it can be difficult to return him to a full life.
People who lead a passive lifestyle and have a curvature of the spine are at risk for developing a hernia and hernia complications, which can become a threat to a full life.
Symptoms and localization of leg pain
It is important to remember that with pathological changes in the segmental roots, classic, bright signs of irritation or loss of function do not always occur, as in the textbook. The boundaries of segmental dermatomes “in real life” are not as clear as in the pictures. The affected areas may be vague: sometimes wider, sometimes narrower. This is also related to the degree of radicular compression. Let us briefly consider the main localizations of protrusions and hernias of the lumbar spine that cause symptoms of pain in the leg.
L5-S1
This is the most “delicate” pair of roots, the last one in the lumbar region between the lower lumbar vertebra and the pelvic ring. It is this spinal segment that bears the heaviest load. And the same segment is the most mobile, having a high risk of spondylolisthesis. If between the third and fourth lumbar vertebrae mobility is 12 degrees relative to the planes of the intervertebral discs, between the fourth and fifth - 16°, then at this level it reaches 20° and higher. Therefore, this disc wears out faster.
Most often, the so-called posterolateral localization of hernias occurs at this level. This is possible because down here the posterior longitudinal ligament does not completely cover the wall of the spinal canal, but only 75%. Therefore, in the event of a hernia prolapse, there is free space from this ligament on the sides, and it is “convenient” for the hernia to fall out backwards, to the side. In the overlying sections, hernias are more often median, or paramedian. This special localization of the hernia affects the L5 root. This leads to the fact that the L5 root, as the upper one, is pinched by the hernia much more often than the first pair of lower sacral roots, despite their excessive tension.
A sequestrated hernia is most severe when the prolapsed sequestrum moves toward the opening of the first cruciate segment. Symptoms of compression will be severe, radiating pain that extends down from the lower back and gluteus maximus muscle. They spread along the back edge of the thigh from the outside, along the edge of the shin also from the outside, to the outer edge of the foot. Very often the pain radiates to the fingers, to the little finger, but very rarely reaches the thumb. Sometimes the pain spreads only to the heel, but also along its outer side.
Very characteristic are tingling, paresthesia and crawling, that is, sensitivity disorders in these areas. If the patient has an acute or subacute stage, then when coughing and sneezing, with strong pressure in the area of the sacral foramina, a sharp increase in radicular pain occurs, and it radiates to the leg. In the same segment, upon careful examination, hypalgesia is noted, that is, a decrease in pain and tactile sensitivity. A neurologist may detect a decrease in the strength of the triceps surae muscle on the affected side, sometimes low tone and hypotrophy of the calf muscle, and a decrease in the strength of the toes, especially the outer edge, that is, the little toe. It is difficult for the patient to stand on his toes on the affected side. When examining reflexes, a decrease in the Achilles reflex or its complete absence on the affected side is noted.
Surprisingly, sometimes instead of hypotrophy of the lower leg muscles, sometimes they paradoxically increase in size. But this should not be attributed to an increase in muscle strength, since such pseudohypertrophy occurs due to vegetative-trophic disorders associated with innervation disorders. The reason here is muscle inflammation, or myositis, as well as venous congestion.
It should be especially noted that the underlying root, S1, can be distinguished from damage to the L5 root by the presence of pronounced autonomic disorders, changes in vascular hemodynamics, microcirculation disorders, and other symptoms that can be seen. These are changes in temperature and skin color, cold feet or excessive heat. A marbled tint of the skin appears, as well as changes in data on ultrasound of the vessels of the lower extremities.
Of all operations for protrusions and hernias in the lumbar spine, patients with damage to the L5 root make up a third of all surgical interventions. If there is a disc herniation L5-S1, then this root will be affected in 95% of cases, and very rarely the isolated S1 root will be affected. If we are talking about hernias one segment higher, level 4-5, then in almost all patients this root becomes involved in the inflammatory process.
L4
This spinal root emerges at a shallower angle than the underlying roots. He is a little smaller than them, shorter than them, and therefore is infringed less often. Another feature of this root can be considered the peculiar structure of the root of its vertebral arch with a peculiar notch. It is quite high, and “spares” the root, so its infringement occurs not in the area of its arch, but in the epidural space.
Therefore, the fourth lumbar root is affected quite rarely, and hernias compress it in approximately 7–10% of all cases. But clinical manifestations of damage to this root are common, although patients undergo surgery in only 17-20% of all cases. The right root is most often affected.
How does damage to this root manifest itself? These are mild pains, usually with a vegetative component. This is a feeling of fullness, burning, cerebral pain. Such unpleasant, hard-to-feel pain usually radiates to the thigh, to the knee, and very rarely below. Irradiation, or spread of pain, is noted along the anterior inner side of the thigh. Paresthesia, or sensory disturbance, occurs in the same area.
When this root is affected, sensitivity disorders usually end at the level of the knee and do not spread to the foot. Approximately the same picture, with a pronounced autonomic component, as well as damage to sensitivity, occurs with compression of the three upper lumbar roots.
Motor function disorders in L4 pathology are associated with dysfunction of the very large quadriceps femoris muscle. The quadriceps femoris straightens the bent leg and allows us to climb stairs. Therefore, such patients experience weakness in the thigh when climbing stairs, but with isolated damage to the 4th root, the knee reflex remains. If it falls out on the affected side, this is due to the fact that in addition to the 4th root, the upper ones, that is, L3, are also affected. After removal of a protrusion or hernia, after microdiscectomy, this root is restored faster than at other levels. By the way, the arc of the knee reflex just closes on this root.
L1-L3
These roots belong to the upper lumbar, and hernias operated for radicular compression at this level are quite rare. This is 3-4% of cases of all operated patients. These roots are usually affected in people over 50 years of age, and the clinical picture at this level is already caused not only by compression of the upper roots, but also by the structures of the cauda equina. A hernia located in this section also affects the conus of the spinal cord - after all, the spinal cord still ends at this level. The period of radicular pain is manifested by a decrease, loss of sensitivity, and pain passes through the skin of the inner and anterior thigh. If the hernia is centrally localized, then symptoms of a cauda equina occur, which will be discussed below. If an upper lumbar hernia stretches the dura mater, then signs of damage to the lower lumbar roots may also appear, because the meninges will also be stretched in the lower section. In some cases, such symptoms of damage to the underlying segments even come to the fore and seem to be the main ones, and this, with the insignificant resolution of the tomograph, can lead to errors.
A very important feature of protrusions and hernias affecting the roots of the upper lumbar spine will be a special, excruciating shade of pain, with a hint of hyperpathy, or increased irritability and excessive pain sensitivity. Paresthesia occurs, quite often in the knee area the patient feels chilliness and numbness, which spreads both above and below the inner surface of the thigh, and the leg “pulls.” This is due to damage to the internal cutaneous nerve of the thigh, which is especially common in older men after a sudden movement.
Pain and loss of sensitivity when the upper roots are affected also occur in the lower back; they periodically radiate along the front surface of the thigh when walking. In this case, there may be weakness, hypotrophy and reduced tone of the quadriceps femoris, a decrease or complete disappearance of the knee reflex, as well as a decrease in sensitivity in the corresponding dermatomes.
Treatment methods
A significant reduction in the symptoms of a lumbar hernia can occur within a few months. It has been found that in some cases this is due to a decrease in the size of the hernia over time. It may dry out over the course of several months. The process of inflammation in the area of the hernia can contribute to its reduction and reduction in size. Sometimes without any treatment.
Lifestyle
Under no circumstances should you just lie down and wait for the pain and symptoms to go away. Even in the acute stage, it is necessary to maintain minimal physical activity, walk, do gymnastics, even while lying in bed. When the acute period passes, it is necessary to strengthen the muscles of the back and abs, improve blood circulation to quickly relieve swelling, inflammation and spasm.
Massage, manual therapy, traction, physiotherapy
It is advisable that the massage be done by a specialist who understands the problem. Sharp techniques and manual therapy techniques are not recommended in the acute period. Various reduction techniques can produce unpredictable results.
All physical impact techniques are just a technique in the complex treatment of pain due to a lumbar hernia, so they must be selected by a doctor.
Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually prescribed for treatment. They help relieve inflammation in the hernia area and reduce pain. Newer NSAIDs have fewer side effects on the digestive system. But if there were problems at first, you need to consult a doctor.
Modern non-steroidal anti-inflammatory drugs:
- movalis;
- Celebrex;
- Arcoxia;
- nimesil.
For unbearable pain, opioid analgesics can be prescribed, but their use is fraught with addiction. This problem is very common in the United States, as doctors often prescribe such drugs in short courses, and the patient continues to take them. Remember the TV series “House” and the addiction of its main character.
Chondroprotectors are often prescribed in the form of injections and capsules. Such drugs cannot cure a hernia if it already exists. Their use can help slow down the destruction of intervertebral discs and joint damage. You can read more about what types of chondroprotectors there are and how they work in the article.
Chondroprotectors are used as an additional method of treatment, but not the main one.
Operation
One of the most common methods of treating lumbar hernia is surgery. There are many techniques, techniques, and equipment for carrying it out. Their goal is the same - to mechanically remove the hernia, which compresses the nerves. If earlier operations were performed through large incisions, today technology helps to carry them out through just a few punctures. Also, hernias are not only “cut out,” but also “evaporated” by heating with a special electrode.
The only question remains is who has mastered all the methods and techniques of operations and will select the appropriate method for each specific case.
Dangers of the operation
Surgery may seem like a radical but effective treatment method. Having suffered enough with pain, having lost hope, time and money, having tried other methods, a person hopes for surgery. What could be better than removing the hernia itself?
The need for surgical intervention is determined only by doctors, but the patient must be familiar with all possible risks.
Unfortunately, any operation has its own percentage of failures, complications and negative consequences. Even if you choose the best doctor and trust him, you cannot get a 100% guarantee.
What can happen:
- damage to nerves during surgery with subsequent loss of sensitivity, muscle strength, and impaired tissue nutrition;
- bleeding during surgery;
- development of infection;
- the formation of scars and adhesions, which can again compress the nerve and maintain symptoms;
- recurrence of disc herniation is possible (up to 8%);
- error in choosing the level of surgery (it is not easy to accurately compare the x-ray and the actual level of the disc on the body, especially in obese people; variability in the structure of the spine).
At the same time, delaying surgery can aggravate the situation and lead to irreversible changes in the tissues surrounding the nerve. This can complicate the operation and reduce its effectiveness.
Conus-epiconus syndrome
At the end of the spinal cord there are two structures: the conus and the epiconus. The cone corresponds to the lower sacral segments and the structures of the coccygeal region. It provides autonomic innervation to the pelvic organs, but does not supply motor branches to the legs. The epiconus, which is located above, “manages” the segments from L4 to S2; it contains neurons that innervate the muscles from the sciatic nerve.
If the epiconus of the spinal cord is affected, there will be flaccid paralysis of the foot and buttock, and the Achilles reflex will be absent. Sensory disturbances will be in the anogenital area, while in the case of a strict lesion of only the conus, only the anogenital area will be affected. The epiconus lesion will be wider, in the form of the so-called “rider's pants”. If the cone is involved, then the patient will experience urinary and fecal incontinence, and of a true nature. If damage to the epiconus is added, then conduction disorders will also form typical urinary retention. Classic cauda equina syndrome is manifested by sharp, severe shooting pains in the hips and perineum, unilateral disturbances of pain and temperature sensitivity in the legs often occur, pelvic disorders and numbness of the perineum sometimes appear, and impotence develops in men.
Signs of neuropathic pain in the leg due to hernia
In most cases, pain in the leg due to intervertebral hernia occurs due to damage to the nerve fiber. This can happen on several levels:
- pinching of the radicular nerve at the exit from the foraminal opening in the vertebra (pressure from a hernial protrusion or deformed surrounding tissues, developing osteophytes);
- compression of the branches of the radicular nerve by spasmed muscles and overstrained ligaments (secondary complex of inflammation during disc herniation);
- pressure and inflammation of the lumbosacral nerve plexus and the nerves extending from it, responsible for the innervation of the lower limb.
Periodically appearing pain in the leg due to a vertebral hernia is a sign that the traumatic effect on the nerve fiber is not constant. In this case, it is important to identify and eliminate the cause of repeated compression of the radicular nerve.
Pain in the left leg most often occurs with a herniated spine; this is due to the fact that increased static muscle tension occurs on the right side. As a result, compression of the paired root nerve on the left side is observed.
Neuropathic pain in the legs due to a hernia has a number of characteristic symptoms, which are accompanied by:
- usually occurs after heavy physical activity or after performing the same type of monotonous movements with the body or legs;
- with it there is a feeling of numbness of the skin in certain areas of the lower limb;
- muscle weakness and fatigue occur when walking the usual distances;
- in the evening and at night there are quite strong cramps of the thigh and calf muscles, which gradually turn into restless legs syndrome (it does not allow you to go to sleep, it forces you to wake up in the middle of the night);
- signs of vascular insufficiency appear (local temperature decreases, skin becomes pale, dense persistent swelling around the ankle joint may develop);
- When bending forward, the pain subsides.
Prolonged neuropathic pain in the legs cannot be present with a spinal hernia. If pressure or ischemia is not eliminated, then nerve fiber atrophy occurs. This process is accompanied by a gradual fading of the pain syndrome. But at the same time, signs of neuropathy increase. Pallor of the skin worsens, muscle weakness increases. Against the background of complete atrophy of the nerve fiber, complete paralysis or partial paresis of individual muscles of the thigh and leg can be observed.
If such pain occurs, it is necessary to conduct an MRI examination of the lumbosacral spine. If a disc herniation is detected, treatment should begin immediately. The sooner medical assistance is provided, the higher the chances of complete restoration of the health of the spinal column.
Why does pain occur with a vertebral hernia?
From the above, it is clear that pain in the presence of destruction of the intervertebral disc is formed not only from the fact that the destroyed cartilage itself directly compresses the nerve roots. This can be done by fascia and ligaments, and they are stretched from the hernia at a sufficient distance. The pain component is associated with various types of pain in color, the appearance of sensory and autonomic disorders, disruption of autonomic-vascular innervation, venous disorder and muscle swelling.
Finally, one cannot help but remember the component of secondary muscle spasm, which occurs as diffuse, low-intensity pain in the back and lower back, disturbing for weeks and months. In some cases, muscles, being subject to spasm, form a local persistent pain syndrome, for example, the piriformis muscle. The neurologist needs an accurate topical diagnosis related to the correct localization of the lesion.
How does a hernia occur?
Normally, there are intervertebral discs between the vertebrae. They perform a shock-absorbing function. The disc itself consists of a nucleus pulposus containing up to 80% water. Around it there is a fibrous ring.
With age, various microtraumas and disturbances in the structure of the fibrous ring occur. Eventually, cracks appear in the disc and the vertebrae between which the disc is sandwiched begin to squeeze out some of the contents through the defect, which is how a hernia appears. It can be very small or large. With a large defect in the annulus fibrosus, the hernia can completely separate from the intervertebral disc.
Possible complications
In itself, severe pain in the lower back with radiation to the leg is a factor that significantly worsens the quality of life. If pain lasts for more than 2 months, which cannot be relieved with conservative methods, surgical intervention is indicated. If the pain is accompanied by:
- movement disorders;
- progressive weakness in the muscles of the limbs;
- expansion of the zone of sensitivity disorders;
- progressive muscle wasting;
- inhibition of tendon reflexes;
- the appearance of pelvic disorders.
Then the decision on surgical intervention must be made as quickly as possible.
Complications of certain types of intervertebral hernias will be persistent dysfunction of the pelvic organs, imperative urge to urinate, then true urinary and fecal incontinence, shooting pains in the legs, as well as progression of paralysis.
Finally, with damage to the upper lumbar segments with the phenomenon of compression of the dural sac and spinal cord, myelopathy can develop, which will no longer be one-sided. The progression of bilateral peripheral paralysis in combination with dysfunction of the pelvic organs will turn the patient into a profound disability who will use a wheelchair. Considering that this can be avoided in many cases, it is necessary to carry out accurate instrumental diagnostics as quickly as possible and choose a treatment method.
Schmorl's hernia
This type of hernia is considered the “lesser evil” among all types. It is inherited and is characterized by concavity of closely lying plates of vertebral segments. It does not affect the lifestyle in any way, however, it is not subject to treatment.
The only thing that can happen with such a formation is an increased risk of fractures. This nuance is explained by the weakness of the lumbar vertebrae. When a patient is diagnosed with this type of hernia, doctors recommend limiting physical activity and engaging in physical therapy.