A herniated disc is a spinal disc whose soft center has pushed out through its tough outer wall. A spinal disc has a tough, fiber outer ring and a softer, gel-like center. In a herniation, part of that center pushes through a weak spot in the ring. It ends up where it does not belong — usually a few millimeters from a nerve root.
The pain from a herniated disc is mostly not about pressure. It is about chemistry and inflammation. The body treats the disc’s center as foreign. When it escapes, it sets off inflammation that sensitizes the nearby nerve root. That is why a small herniation can cause fierce leg pain while a large one can cause almost none. It is also why anti-inflammatory treatment aimed at the nerve often works before anything has physically moved.
Herniations are most common between the ages of 30 and 55. That surprises people who expect a wear-and-tear problem to strike the very old. A younger disc still has enough water in its center to be pushed out under pressure. A badly worn disc has less to push out.
The factors that really matter: repeated bending and lifting under load, most of all with twisting. Long sitting. Smoking, which starves the already thin blood supply the disc depends on. And metabolic disease. That last one is usually left out. Insulin resistance, visceral fat (deep belly fat around the organs) and chronic inflammation change disc nutrition and the inflammation around a nerve root. That affects both whether a herniation hurts and how fast it settles. This practice treats those along with the structural problem — see lifestyle medicine and medical weight management.
It also helps to know that herniation is a common finding in people with no symptoms at all. According to PubMed, a review of imaging in people without symptoms found disc protrusions in 29 percent of 20-year-olds, rising to 43 percent of 80-year-olds. Disc bulges rose from 30 percent to 84 percent (Brinjikji W, et al. AJNR Am J Neuroradiol. 2015;36(4):811-6. DOI). A herniation on your scan is a finding. Whether it is your finding is a separate question.
The defining feature is that the leg or the arm hurts more than the back.
When symptoms are in the arm instead of the leg, the cause is the same and the evaluation is the same. Our post on cervical radiculopathy covers that case.
Fast-worsening weakness, numbness in the saddle area, or new trouble controlling bowel or bladder is checked urgently, not scheduled. Call us or go to an emergency department.
Examination first, and it settles more than patients expect. Which reflex is weaker, which muscle is weak, and which strip of skin feels different? Do nerve-stretch tests bring on the exact pain? These point to a specific nerve root before anyone looks at a scan. A good exam produces a theory. Then the scan is asked to confirm or reject it.
Imaging read against symptoms, not in isolation. MRI shows disc material and how close it sits to the nerve. Herniations show up so often in people with no pain that the report alone does not make the diagnosis. What makes it is agreement. The level and side of the herniation must explain the level and side of the symptoms. When they disagree — and they often do — we sort that out before treating anything. We do not paper over it. See what each imaging modality can and cannot tell you.
Nerve testing where the picture is mixed. EMG and nerve conduction studies tell a pinched nerve root apart from a nerve trapped further out or diabetic nerve damage. That difference changes the treatment completely.
A diagnostic block where more than one level could be responsible. Sometimes two neighboring levels both look possible. Then a selective nerve root block under image guidance numbs one root at a time. If the pain goes while the drug works, that root is the source. That is a test with an answer. It prevents a procedure aimed at the wrong level.
This is the most useful thing most patients are never told: herniated discs often shrink back on their own.
According to PubMed, a pooled analysis of 11 group studies looked at low back disc herniations treated without surgery. Overall, 66.7 percent shrank back on their own (Zhong M, et al. Pain Physician. 2017;20(1):E45-E52. PubMed — no DOI assigned). About two in three shrank or disappeared without an operation.
That figure does not mean you should simply wait. It means early treatment aims to control inflammation and keep you functioning while nature does its work. And a choice to operate is made knowing that most of these clear up. It also comes with the usual warning. The pooled studies observed groups over time. They were not randomized trials, and the review’s authors said so plainly.
Conservative care. Change activities without bed rest, do targeted physical therapy, and use nerve pain medicine when it fits. Losing fitness makes this worse, not better. So the aim is to keep moving within what you can handle.
Image-guided injections. Epidural steroid injections and selective nerve root blocks place anti-inflammatory medicine right where the inflamed root is. You are not asking a pill to find it. They often buy the months in which the disc shrinks back. They are done under local numbing with no sedation. Patients are awake, drive themselves home, and are back to normal activity, including work, within two to four hours.
Metabolic and inflammatory drivers. Treated here, not referred out, for the reasons above.
Neuromodulation where pain persists. For patients whose nerve pain outlasts the herniation — including after surgery — spinal cord stimulation and peripheral nerve stimulation are options. Each is tested with a trial before anything is implanted.
This is one of the conditions where surgery has a clear, well-defined role, and this practice performs it. Dr. Gurpreet Singh Padda, MD, MBA, MHP is a licensed physician and surgeon with surgical privileges. Microdiscectomy — removing the fragment that presses on the nerve — is among the procedures done here.
It is the right answer in three cases. There is weakness that keeps getting worse. There is cauda equina compression (pressure on the bundle of nerves at the base of the spine). Or severe nerve pain that matches the imaging has not responded to a real course of conservative (non-surgical) and interventional care. It is not the right answer to an MRI report in a patient who is getting better. And it is a poor answer to back pain without a pinched nerve, which is a different problem with different causes.
The evidence comparing the two is worth stating without spin. According to PubMed, the Spine Patient Outcomes Research Trial followed patients with low back disc herniation confirmed on imaging. Some had surgery and some did not, across 13 US spine clinics. At four years, by treatment received, surgery patients improved more on pain, physical function and disability. Yet the share working was about the same in both groups: 84.4 percent against 78.4 percent (Weinstein JN, et al. Spine (Phila Pa 1976). 2008;33(25):2789-800. DOI).
Two things about that trial matter for reading it honestly. Many patients crossed from one group to the other. That is why the analysis by assigned group understated the effect, and why the analysis by treatment received must be read with care. And the trial picked patients whose imaging and symptoms already agreed. That is exactly the filter that decides whether an operation helps. And it is exactly the filter many patients have never been put through.
So the order is: confirm the level, control the inflammation, give nature a fair chance, and operate on the patients who have finished that order, not skipped it.
Leg or arm pain that follows one line, with a matching change in feeling or strength, is a specific problem we can test. We see patients from across St. Louis, Bridgeton, St. Charles and the Illinois Metro East. Call us or request an evaluation.
Most herniated discs settle without surgery. When pain lingers in the joints and ligaments around the injured level, PRP injections and bone marrow concentrate are options that use your own cells. See the full overview of orthobiologic treatment.
More on this condition from Dr. Padda on YouTube:
Often, yes. A pooled analysis of 11 group studies found that about two thirds of low back disc herniations treated without surgery shrank back on their own. That does not mean doing nothing. It means early treatment aims to control the inflammation around the nerve and keep you functioning while nature works. Surgery is a choice made against that background. Read more: Sciatica: disc, piriformis or cluneal nerve? and what a selective nerve root block actually proves.
No. A bulge is a broad, even spread of the disc past its normal edge. A herniation is a focused push of the disc’s center through the fiber ring. Bulges are very common in people with no symptoms. A review of imaging in people without symptoms found them in 30 percent of 20-year-olds and 84 percent of 80-year-olds. Neither finding is a diagnosis on its own. Read more: When the scan does not match the pain.
Because the pain comes from an inflamed, sensitized nerve root, and that root’s job is to carry feeling from your leg. The brain reads the signal as coming from where the nerve ends, not from where it is being irritated. That is also why the pain follows a line instead of spreading in a patch. And it is why treating the root, not the back, is what works. Read more: Pain is a signal, not the disease.
No. They are done under local numbing with the patient awake and able to respond. Most patients drive themselves home and are back to normal activity, including work, within two to four hours. The one exception is short-term leg weakness or numbness. An epidural can sometimes cause it, and it goes away. If it happens, we wait it out with you instead of sending you off. Read more: How an epidural steroid injection actually works.
There is no magic number and no fixed series. Need decides. How much relief did the last injection give, and how long did it last? What has changed on exam? What is the plan building toward? A treatment that is working and a treatment that has stopped working are different situations. They get different answers. Read more: Why pain injections stop working.
It is a targeted one. The fragment pressing on the nerve is removed through a small opening. The rest of the disc and the spine’s alignment stay intact. It is not a fusion, and nothing is implanted. That is a real plus for what stays possible later. Whether you need one depends on whether your imaging, your exam and your symptoms all point at the same nerve root. Read more: Orthopedic surgeon, neurosurgeon or pain physician?
Because removing the pressure is not the same as undoing what the pressure did. A nerve root that has been inflamed and sensitized for months can keep making pain after the mechanical problem is gone. And scar tissue around the root is its own separate process. Both can be treated, and neither means the operation failed. Read more: Why leg pain persists after back surgery.
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