Herniated Disc
A herniated disc occurs when the soft inner core of a spinal disc ruptures through its outer layer, compressing sensitive nerves. Dr. Rojeh Melikian, an award-winning, fellowship-trained, board-certified spine surgeon with training at Harvard and Emory, offers individualized care that addresses the root cause. He delivers expert diagnostic clarity, minimally invasive treatments for rapid recovery and a partnership to restore your lifestyle.
What Is a Herniated Disc?
Your spine consists of vertebrae with discs in between that act as shock absorbers. Each disc has an outer shell and an inner jelly-like core called the nucleus pulposus. When the outer shell tears, that inner material can push out and compress nearby nerves, causing pain and other symptoms.
Symptoms will vary by disc location:
- Cervical herniated disc: Neck herniations produce sharp pain, numbness, or tingling radiating down your shoulder, arm, or hand. Severe cases can cause cord compression, or cervical myelopathy, leading to hand clumsiness and gait instability, symptoms that require immediate attention.
- Lumbar herniated disc: Lower back herniations trigger debilitating sciatica, burning pain or weakness shooting down your buttocks and leg. In some cases, the herniation may contribute to foraminal stenosis, narrowing the openings where nerve roots exit the spine.
Understanding herniation grades gives you confidence about the severity. Here’s what you need to know about the different herniated disc grades:
- Protrusion: The disc bulges outward while the outer layer remains intact. The base is wider than the portion extending into the spinal canal.
- Extrusion: The outer wall tears completely, allowing the inner gel to escape. At least one dimension exceeds the diameter of the rupture site.
- Sequestration: A fragment breaks off entirely, causing severe inflammation and nerve compression.
Common Herniated Disc Risk Factors and Causes
Multiple factors can contribute to disc herniation. Age-related wear reduces disc flexibility. Repetitive strain, improper lifting and trauma cause ruptures. Meanwhile, certain genetic predispositions, excess weight, smoking and prolonged sitting increase risk by adding compressive load and reducing disc nutrition.
Once a disc herniates, it can affect nerve roots in one of two ways. The first and most obvious mechanism is through sheer pressure, causing physical trauma to the nerve roots. The chemical makeup of the nucleus pulposus is very irritating to nerves and causes a large inflammatory response when it contacts a nerve root. This explains why even small disc herniations can still be extremely painful.
Herniated Disc Treatment Options
Your doctor will perform a history and physical exam to see if your symptoms are consistent with a ruptured disc. If appropriate, an MRI of your neck or back will show the exact location and size of the herniation.
Treatment goals are to relieve the discomfort and prevent nerve injury. Treatments can include medications, physical therapy, epidural steroid injections, surgery or a combination of approaches. Depending on the location and size of the disc, surgical intervention may consist of removing only the piece of the disc that has herniated or removing the entire disc.
Many herniations can resolve through nonsurgical management. Targeted physical therapy strengthens core musculature. Anti-inflammatory medications reduce nerve irritation. Epidural steroid injections deliver medication directly to inflamed nerve roots. When conservative care fails, surgical intervention provides relief.
The most common symptoms of spondylolisthesis tend to back, buttock and leg pain. The buttock and leg pain is caused by narrowing of the area where the nerves leave the spinal canal. Symptoms tend to be worse when patients stand up and somewhat better with laying down. This is usually because the forward slippage tends to worsen as you stand up and slips back towards normal when you lay down.
Spondylolisthesis can be diagnosed with an X-ray which will show the area of slippage. As can be see in figure 2, the back of the vertebral bodies should form a smooth line. However, down between the two vertebral bodies highlighted in yellow, you can see where there is a step-off in the red line. This is the area of slippage. An MRI will be able to show the amount of nerve compression associated with the spondylolisthesis. However, keep in mind the MRI in this situation will tend to under call the amount of nerve compression as the slippage tends to decrease when you are laying down (most MRIs are done with you laying on your back).
For those without neurological impairment, meaning weakness in their legs as a result of nerve compression, the first line of treatment options consists of conservative measures such as anti-inflammatory medications and physical therapy. Epidural injections are also a treatment option if the buttock and leg pain are particularly bothersome.
Should more conservative measures fail or leg weakness develop, surgical treatments can be discussed. Surgical treatments for spondylolisthesis, and most spine surgery in general, come in two flavors: decompression alone vs. decompression and fusion. The decompression surgery alone involves removing the portions of bone and soft tissue which are pushing on the nerve roots but does not compromise any of the motion. Adding the fusion allows for the restoration of spinal stability by fusing the two slipped vertebrae together. It also allows for a wider decompression of the nerve roots.
Contact us for an appointment to discuss both options and see which is appropriate for you.
Advanced Herniated Disc Surgery for Accelerated Recovery
Dr. Melikian’s minimally invasive techniques prioritize patient safety when surgery becomes necessary, supported by his zero MRSA infection rate to date. For lumbar herniations, microdiscectomy is commonly performed to remove only compressive disc material while preserving healthy tissue. This approach includes smaller incisions, preserved muscle integrity and same-day discharge.
Herniated Disc Prevention Strategies
While not all disc herniations are preventable, maintaining core strength through regular exercise, practicing proper lifting techniques, maintaining a healthy weight and avoiding prolonged sitting can help protect your spine.
The most common symptoms of spinal stenosis tend to be neck or back pain accompanied by arm or leg pain (depending on which portion of your spine is affected). If your spinal stenosis is in your lumbar spine, patients tend to complain of back, buttock and leg pain which worsens with standing and sitting. It tends to be relieved with sitting, laying down or leaning over. A common scenario is someone who experiences relief of the pain when leaning on a shopping cart. This is because leaning forward tends to open up the passageways for your nerves, which results in a reduction in symptoms.
If your spinal stenosis is in your cervical spine, the symptoms you experience can be different. Most patients will have some neck pain. You may also experience arm pain to accompany it. The difference with cervical stenosis, unlike lumbar stenosis, is that it tends to affect your spinal cord rather than just the individual nerve roots. This can result in balance issues (feeling unsteady on your feet), difficulty coordinating your hands (buttoning shirts, using zippers), or dropping objects out of your hands. In severe cases, both cervical and lumbar stenosis can result in loss of control of bowel and bladder.
Spinal stenosis is typically diagnosed using an MRI. This will show narrowing of the spinal canal where the nerves travel. If you are unable to get an MRI, a CT scan can also show the narrowing of your spinal canal. Figure 3 shows two MRI cross-sections demonstrating a normal spinal canal and one with cervical stenosis. The yellow lines outline the spinal cord itself while the blue lines highlight the edges of the spinal canal (the space available for the spinal cord to float in). On the left panel is a normal canal with plenty of space around the spinal cord. The white area around the spinal cord is filled with cerebrospinal fluid which acts like a watery cushion in which the spinal cord floats. On the right panel is the MRI of a patient with spinal stenosis. As you can see, the spinal cord shape is deformed from an ellipse into a boomerang shape and there is absolutely no cerebrospinal fluid around it. The spinal canal borders (marked in blue) are so narrow, they are causing spinal cord compression.
Depending on the location and severity of your spinal stenosis, several different treatment options are available. For both cervical and lumbar stenosis, treatments can begin with modifying your activities, participating in physical therapy, and/or epidural steroid injections. Should your stenosis be severe enough to cause arm or leg weakness or should conservative treatments fail, you may be a candidate for a minimally-invasive, microscopic decompression or a minimally-invasive decompression and fusion. The treatment choice depends on the location of your stenosis, the severity of the stenosis and whether or not you have other structural issues in your spine which may necessitate a fusion.
Book an Appointment With a Fellowship-Trained Spine Specialist
Chronic spinal pain requires individualized care for lasting relief. Dr. Melikian’s fellowship training, commitment to patient safety and minimally invasive approach position you for optimal outcomes. Call 949-806-6946 or schedule your appointment online, either for an in-person or virtual consultation via video or phone.