Slipped disc
Introduction
A slipped disc, also called a prolapsed or herniated disc, occurs when one of the discs of the spine is ruptured (splits) and the gel inside leaks out. This causes back pain and can also cause pain in other areas of the body.
The spine
The spine is made up of 24 individual bones called vertebrae, which are stacked on top of each other. Discs are the protective, circular pads of cartilage (connective tissue) that lie in between the vertebrae. The discs are responsible for cushioning the vertebrae when jumping or running.
The spinal cord is a collection of nerve fibres that are attached to the brain and are protected by the spine. Nerve fibres from the spinal cord pass between the vertebrae as they take and receive messages to and from different parts of the body.
A slipped disc
The discs are made from a tough, fibrous case, which contains a softer, gel-like substance. A slipped disc occurs when the outer part of the disc ruptures (splits), allowing the gel inside to bulge and protrude outwards between the vertebrae.
The damaged disc can put pressure on the whole spinal cord or on a single nerve fibre. This means that a slipped disc can cause pain both in the area of the protruding disc and in any part of the body that is controlled by the nerve that the disc is pressing on.
How common is a slipped disc?
Slipped discs are most common in people between the ages of 30 and 50. The condition affects twice as many men as women.
A slipped disc occurs most frequently in the lower back, but any disc can rupture, including those in the upper back and neck. Around one-third of adults in the UK have lower back pain, and a slipped disc is responsible in less than 1 in 20 cases.
Outlook
It can take around four to six weeks to recover from a slipped disc. In most cases, treatment involves a combination of physical therapy, such as exercise and massage, and medication to relieve the pain.
In severe cases, or if the pain continues for longer than six weeks, surgery may be considered. A number of different procedures can release the compressed nerve and remove part of the disc. The success rate for surgery on the lumber (lower) spine is around 60-90%.
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Symptoms
Some people who have a slipped disc experience no obvious symptoms. This is usually because the part of the disc that bulges out is only small or may not be pressing on the nerves or spinal cord.
However, most people who have a slipped disc will experience pain. The pain often begins in the lower back before sometimes spreading to other parts of the body.
Sciatica
With most slipped discs, pain is caused when part of the disc begins to press on one of the nerves that run along the spine. The sciatic nerve is the most commonly affected nerve.
The sciatic nerve is the longest nerve in the body and is made up of several smaller nerves. It runs from the back of the pelvis, through the buttocks and all the way down both legs, ending at the feet.
If you have pressure on the sciatic nerve, it can cause:
- a lasting, aching pain
- numbness
- a tingling sensation in one or both of your legs
These symptoms often start in the lower back and travel down the buttocks, into either of the legs.
See the topic about Sciatica for more information about pain that is caused by compression on the sciatic nerve.
Other nerves
If the slipped disc presses on any of the other nerves that run down your spinal cord, your symptoms may include:
- muscle paralysis (weakness)
- muscle spasms, when your muscles contract tightly and painfully
- loss of bladder control
Muscle spasms and paralysis tend to occur in your arms, legs and buttocks. The pain that you experience when a disc presses on a nerve is often worse when you put pressure on the nerve. This can happen when you:
Cauda equina syndrome
Cauda equina syndrome is a serious condition where the nerves at the very bottom of the spinal cord become compressed. Symptoms of the syndrome include:
- lower back pain
- numbness in your groin
- paralysis of one or both legs
- rectum pain (pain in the lower bowel and anus)
- bowel disturbance
- being unable to pass urine
- pain in the inside of your thighs
If you develop any of these symptoms, contact your GP immediately or visit the accident and emergency (A&E) department of your nearest hospital.
If cauda equina syndrome is not promptly treated, the nerves to your bladder and bowel can become permanently damaged.
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Causes
A slipped disc occurs when the circle of connective tissue (the tissue that provides support and structure to other tissues and organs) surrounding the disc breaks down. This allows the soft, gel-like part of the disc to swell and protrude out.
It is not always clear what causes the connective tissue to break down. Many cases of slipped discs are the result of increasing age. As you get older, your spinal discs start to lose their water content, making them less flexible and more likely to rupture (split).
A number of other factors can put increased pressure and strain on your spine, including:
- bending awkwardly
- having a job that involves heavy or awkward lifting
- having a job that involves lots of sitting (particularly driving)
- smoking
- being overweight
- participating in a weight-bearing sport, such as weight lifting
- having a traumatic injury to your back, such as a fall or car accident
These situations or events can weaken the disc tissue, which can lead to a slipped disc.
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Diagnosis
Your GP can usually diagnose a slipped disc from your symptoms and medical history. You will also have a physical examination, during which your GP will test your:
- reflexes
- muscles strength
- walking ability
- sensation in your limbs
Straight leg-raising test
While you are lying flat, your GP will slowly raise each of your legs, one at a time, to see if this causes any pain or discomfort in your legs or back. This is known as the straight leg raising test.
Most people with a slipped disc will not be able to raise their leg more than two thirds of the way up without feeling tingling, numbness and pain.
Further tests
Most cases of slipped disc do not require further testing because the symptoms will usually settle down within a few weeks. However, if your symptoms do not ease after four to six weeks, you may require further tests to rule out other conditions and investigate the size and position of the slipped disc.
Magnetic resonance imaging (MRI) scans
A magnetic resonance imaging (MRI) scan uses a strong magnetic field and radio waves to produce detailed images of the inside of your body. MRI scans are very effective at showing the position and size of a slipped disc. They can also pinpoint which nerves are being affected.
See the topic about MRI scan for more information.
Computerised Tomography (CT) scan
A computerised tomography (CT) scan uses a series of X-rays to scan parts of your body. A computer is then used to build up detailed images of your body. This produces cross sectional images of your spinal column and the structures that surround it. Like an MRI scan, a CT scan can pinpoint a slipped disc, although it is often not as effective as an MRI scan.
See the topic about CT scan for more information.
Discography
A discography is a test that involves injecting a special dye into the disc in your spine. An X-ray is then taken to show how the dye has spread around your back. The image will reveal any tears or leaks from your disc.
Other causes
The tests listed below can be used to check that your back pain is not caused by another health condition such as:
- a tumour (growth)
- an infection
- arthritis (a painful condition that affects the joints and bones)
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Treatment
Recovery from a slipped disc usually takes four to six weeks. To recover from a slipped disc, most people will need to do some gentle exercises, and painkilling medication may also be required.
In most cases, a disc that bulges out from between your vertebrae (bones of the spine) will eventually shrink back. The pain will usually ease as the disc stops pressing on the affected nerve.
Keeping active
It is very important to keep active if you have been diagnosed with a slipped disc. You may find it difficult to move around immediately after experiencing a slipped disc. If you are in severe pain, you may need to rest completely for the first couple of days. However, after this period, you should start to move around as soon as you can. This will keep your back mobile and will speed up your recovery.
It is very important for you to ensure that any exercise you do is gentle and has a low impact on your back. Swimming, for example, puts very little strain on your joints as the water supports your weight. Movement and exercise will also help to strengthen any muscles that have become weak. Avoid any activities that could aggravate your condition, such as:
- reaching
- lifting
- sitting for a prolonged period of time
Physical therapy
As part of your treatment programme, you may be referred to a physiotherapist. A physiotherapist will be able to draw up an individually tailored exercise plan for you. This will keep you active, minimise pain and help prevent any further damage being caused to your back.
See the topic about Physiotherapy for more information.
You may also be referred to an osteopath or a chiropractor. An osteopath uses a mix of gentle and forceful massage techniques to help reduce pain and swelling. A chiropractor uses careful manipulation of the joints and muscles to help relieve pain.
Medication
There are several different types of medicines that you may be prescribed to help ease the symptoms of a slipped disc. These are described in more detail below.
- Analgesics (painkillers), such as paracetamol: paracetamol is available over-the-counter (OTC) from pharmacies or may be prescribed by your GP. Always read the manufacturer’s instructions before using it.
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, diclofenac and naproxen: these can help relieve pain and reduce any inflammation (swelling and redness). They may not be suitable for people with high blood pressure (hypertension), asthma, heart failure or kidney failure, so always read the manufacturer’s instructions before use.
- Codeine (a stronger type of painkiller), often taken in combination with paracetamol: codeine is usually only prescribed when other painkillers and NSAIDs have not worked. It can cause side effects, such as constipation (feeling unable to empty your bowels).
- Corticosteroid (steroid) injections: corticosteroids are a type of medication that contain hormones (powerful chemicals that have a wide range of effects on your body). They may be injected into your lower spine to help reduce inflammation.
- Muscle relaxants, such as diazepam: you may be prescribed a muscle relaxant to take for a few days if your back or leg muscles are very tense.
Surgery
Approximately 1 in 10 cases of a slipped disc will require surgery. Surgery may be considered if:
- there is evidence of severe nerve compression
- your symptoms have not improved using other treatments
- you are having difficulty standing or walking
- you have very severe symptoms, such as progressive muscle weakness or altered bladder function
The aim of surgery is to cut away the piece of the disc that bulges out. This is known as a discectomy and can be done in several ways. Some of these procedures are explained in more detail below.
Open discectomy
An open discectomy is a procedure to remove part or all of the slipped disc. This will be done under anaesthetic (painkilling medication). An incision (cut) will be made in your spine and the disc will be removed.
See the topic about Lumbar decompressive surgery - how it is performed for more information about this type of surgery.
Prosthetic intervertebral disc replacement
Prosthetic intervertebral disc replacement involves having a prosthetic (artificial) disc inserted into your back to replace the slipped disc. The procedure will be performed under general anaesthetic so you will be unconscious and unable to feel any pain.
An incision will be made in your spine, and the damaged disc will be either partially or completely removed. A replacement disc will then be inserted into the space. One study found that 87% of people felt that their quality of life had improved three months after having this procedure.
Endoscopic laser discectomy
Endoscopic laser surgery involves making a small incision (cut) to access the spine and using an endoscope to view the disc. An endoscope is a thin, long, flexible tube that has a light source and a camera at one end. The procedure is performed under either local or general anaesthetic, depending on where in your spine your slipped disc is.
After the incision has been made, the compressed nerve that is causing you pain will be released and part of your disc will be removed with a laser.
One study found that 67% of people could move around more easily six months after having endoscopic laser surgery, and around 30% of people needed less pain relieving medication. Around 2-4% of people needed another operation. Another study reported that, on average, people returned to work after seven weeks.
At the moment, endoscopic laser surgery is still a new procedure that is only likely to be performed with special arrangements, for example as part of a clinical trial (medical research that tests one type of treatment against another).
Recovery
For most people, this type of back surgery helps to ease symptoms. You can usually return to work after two to six weeks. However, the surgery does not work for everyone, and you may require further operations and treatment if the initial surgery does not work.
Possible complications resulting from surgery may include:
- an infection
- nerve injury
- haemorrhage (severe bleeding)
- temporary dysaesthesia (impaired sense, for example not being able to sense touch)
Before having surgery, ask your surgeon what complications you may be at risk of developing and how long it will take to recover. You may be given a rehabilitation programme to follow.
One review of a number of studies found that exercise programmes which started four to six weeks after surgery on the lumbar spine (lower back) helped to:
- decrease pain
- improve people’s ability to function
See the topics about Lumbar decompressive surgery - risks and Lumbar decompressive surgery - recovery for more detailed information about these aspects of surgery.
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Prevention
A few sensible precautions, such as leading a healthy lifestyle, can help you prevent back pain or a slipped disc. See the topic on Back pain - prevention for more information about how to avoid hurting your back.
Exercise
Regular exercise can slow down the age-related deterioration of the discs in your back. It can also help keep your supporting back muscles strong and supple.
Before and after any workout or sports activity, warm up and cool down properly. Your warm up and cool down should incorporate stretching exercises. If you are recovering from a slipped disc, it is important to avoid high-impact activities, such as jogging and aerobics.
Lifting
Use the correct techniques for lifting. When you are lifting a heavy object:
- think before you lift and make sure that you can manage the weight
- slightly bend your back, hips and knees at the start of the lift
- keep the load close to your waist
- avoid twisting your back or leaning sideways
- keep your head up and look ahead as you carry the load
Seating
Make sure that you have a comfortable, supportive seat when sitting or driving for long periods. If possible, take regular breaks to stretch and walk around.
If you work at a computer, take regular breaks away from your computer screen, every hour. Make sure that the computer screen is at eye level and directly in front of you so that you do not have to twist or bend to see it. Sit in a comfortable position with enough space to move around, and do not stay in the same position for too long.
Your employer may give you a guide to working with computers, which will advise you about the best way to sit and position your equipment.
Weight
If you are overweight, you will put extra strain and pressure on your back. Therefore, maintaining a healthy weight will help ease the pressure. See the Healthy weight calculator to find out if you are a healthy weight for your height.
Posture
Always try to keep good posture. Walk or stand with your head and shoulders slightly back. When sitting at a desk, make sure that your chair is the correct height for the desk. Your feet should be able to rest flat on the floor with your knees bent at 90 degrees.
Mattress
To help avoid back pain, sleep on a bed with a mattress that matches and supports your spine's natural curves.
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