Intervertebral disc herniation: prevention, diagnosis and when to see a doctor

The diagnosis of a "disc herniation" frightens many athletes, although most cases resolve successfully without surgery. Something else is important: to be able to recognise the symptoms, not take unnecessary images and at the same time not miss the rare but dangerous conditions that require urgent help. The editorial team has prepared a practical overview of prevention, diagnosis and signals for seeing a doctor.

Prevention: technique, load, lifestyle

It is impossible to completely eliminate the risk of a herniation, because heredity and age play a significant role. However, training can be organised so as to reduce the accumulation of micro-damage to the disc. The first rule is technique: in deadlifts, squats and bent-over rows the spine should maintain a controlled neutral position, and the movement should occur predominantly at the hip joints.

The second is gradualness. Working weights and volumes should be increased smoothly, especially after a break. The most demanding exercises are better performed at the start of a workout, while the muscles are not tired, rather than at the end, when technique inevitably deteriorates.

The third is the endurance of the trunk muscles. Stabilisation exercises (planks, side planks, the "bird-dog") and general strengthening of the muscles of the hip and glutes help maintain the position of the spine under load. Regular moderate aerobic activity, for example walking, is also useful.

The fourth is outside the gym. Prolonged sitting without breaks, excess weight and smoking worsen the state of the discs. A review in the Lancet on the prevention of back pain emphasises the role of physical activity and patient education as the main evidence-based means of prevention (Foster et al., 2018).

• control of technique and a neutral spine position in basic exercises;
• gradual increase in weights, the hardest exercises — on fresh energy;
• caution with heavy flexion immediately after waking;
• strengthening of the trunk and gluteal muscles;
• breaks in sitting, control of body weight, quitting smoking.

How to recognise a herniation: symptoms

The typical manifestation of a symptomatic lumbar herniation is radicular pain: a burning, "shooting" pain that radiates from the lower back into the buttock and further down the leg below the knee. Often the pain in the leg is stronger than in the back itself. It can intensify with coughing, sneezing, prolonged sitting or a forward lean.

Not infrequently, numbness, tingling or weakness in a particular zone of the leg join the pain. The location of these symptoms depends on which nerve root is irritated and helps the doctor determine the level of the lesion.

It is important to distinguish radicular pain from nonspecific lower-back pain. The latter is a far more frequent situation: back pain without radiation into the leg, linked to load, which usually passes within a few weeks and does not require an MRI.

With a cervical herniation, the pain radiates into the shoulder and arm, and numbness of the fingers and weakness in the arm may appear. Such symptoms in athletes of strength sports or combat athletes also require a doctor's assessment.

Diagnosis: examination and imaging

The diagnosis of a herniation with radicular syndrome is made first of all clinically. The doctor establishes the nature of the pain and assesses mobility, sensitivity, muscle strength and reflexes. One of the classic tests is the straight-leg raise: if it produces pain radiating down the leg, this indicates irritation of a root.

NICE guidelines do not recommend routinely taking images for lower-back pain in primary care; imaging is considered when its result could change treatment tactics, for example when planning surgery or injections (NICE, 2016). A meta-analysis in the Lancet also showed that immediate imaging for back pain without warning signs does not improve treatment outcomes (Chou et al., 2009).

MRI is the method of choice when it is needed: it shows the discs, nerve roots and soft tissues. However, as we wrote in the previous article, disc changes on MRI often occur even in people without symptoms (Brinjikji et al., 2015), so the conclusion of an image is always compared with the clinical picture.

Electroneuromyography is ordered in doubtful cases to assess nerve function and distinguish radicular syndrome from other lesions. Blood tests are needed only if there are signs of infection, inflammation or a suspicion of a tumour.

Treatment: from conservative to surgical

Most patients with a disc herniation without a pronounced neurological deficit are treated conservatively: pain relief, maintaining feasible activity, therapeutic exercise, a gradual return to load. Bed rest is not recommended — it does not speed recovery.

The clinical guidelines of the North American Spine Society summarise that in many patients the symptoms substantially decrease over the first weeks and months (Kreiner et al., 2014). Some herniations decrease in size over time.

Surgical treatment is considered for progressive weakness, cauda equina syndrome or for severe pain that does not decrease despite adequate conservative treatment. A randomised trial in the NEJM showed that early surgery for sciatica provided faster pain relief, but after a year the results of the surgical and conservative groups were similar (Peul et al., 2007). Similar conclusions were reached by the SPORT study (Weinstein et al., 2006).

Epidural corticosteroid injections can give short-term relief of radicular pain in some patients; the decision about them is made by a doctor. For an athlete it is important to remember that systemic and injectable glucocorticoids are regulated by anti-doping rules, so during the competition period a therapeutic-use exemption may be needed.

When to see a doctor

It is worth seeing a doctor on a routine basis if leg pain lasts more than a few weeks, interferes with sleep and everyday activity, or if numbness or slight weakness in the leg has appeared.

Urgent help is needed for signs of cauda equina syndrome: numbness in the perineal area and the inner surface of the thighs, retention or incontinence of urine or stool, disturbance of sexual function, bilateral pain and weakness in the legs. This condition requires urgent surgical assessment, because delay threatens irreversible consequences.

You should also seek help urgently for rapidly increasing weakness of the leg (for example, a "drop" foot), for back pain with fever, unexplained weight loss, a history of cancer, after a significant injury, and also during prolonged use of corticosteroids.

• numbness of the perineum, disturbance of urination or defecation — immediately;
• progressive weakness in the leg — urgently;
• back pain with fever, weight loss, after injury — urgently;
• prolonged radicular pain without improvement — routinely.

Editorial conclusions

Prevention of disc herniation in sport is based on technique, gradual load, endurance of the trunk muscles and a healthy lifestyle outside the gym.

Radicular pain that radiates below the knee, with numbness or weakness, is a typical manifestation of a herniation; the diagnosis is made clinically, and an MRI is done when it changes tactics.

Most cases are treated conservatively, and cauda equina syndrome and progressive weakness require urgent help.

We also recommend reading our materials on the causes of intervertebral disc herniation, on muscle tears in athletes and on therapeutic-use exemptions in anti-doping rules.

References

1. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NICE guideline NG59). London: NICE; 2016.
2. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180–191.
3. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463–472.
4. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356(22):2245–2256.
5. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441–2450.
6. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816.
7. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368–2383.