All about lumbar disc herniation and sciatica
Pain travelling down your leg can make sitting, sleeping, working and even a short walk difficult. A lumbar disc herniation, often called a slipped or prolapsed disc, is a common cause. Most people recover without surgery, but persistent pain or weakness deserves a clear diagnosis and an individual treatment plan.
Modern treatment ranges from rehabilitation and targeted spinal injections to microscopic and endoscopic surgery. Choosing the right approach starts with understanding what is causing your symptoms, how your nerves are affected and what you need to regain your quality of life.
Understanding a lumbar disc herniation
The discs between the bones of your spine act as cushions and allow movement. Each disc has a tough outer ring, called the annulus fibrosus, surrounding a softer, gel-like centre, the nucleus pulposus. A split in the outer ring, known as an annular tear or fissure, can allow some of the inner material to push outwards, forming a disc herniation. These changes can develop gradually and do not necessarily follow an injury. A disc herniation can cause pain through several overlapping mechanisms.
1 - Pain from the disc itself
The outer part of the disc contains pain-sensitive nerve endings, supplied partly by small nerves called the sinuvertebral nerves. An annular tear and associated inflammation can irritate or sensitise these endings, contributing to lower back pain, sometimes felt in the buttocks. This is known as discogenic pain and can occur without significant compression of a spinal nerve.
2 - Inflammation and chemical irritation
A damaged or herniated disc can be associated with the release of inflammatory chemical messengers called cytokines, including tumour necrosis factor alpha and interleukins. These substances can make nearby nerves more sensitive and contribute to pain.
Inflammation around a spinal nerve root is sometimes described as chemical radiculitis. This may help explain why some people experience substantial leg pain even when nerve compression appears relatively modest on their MRI scan.
3 - Pressure on a spinal nerve
Herniated disc material can also physically compress a nerve root, causing pain that travels down the leg, often called sciatica. Depending on which nerve is affected, this may be accompanied by pins and needles, numbness or muscle weakness. The size of a herniation on MRI therefore tells only part of the story. A smaller herniation can be very painful, while a larger one may cause fewer symptoms. Some annular tears and disc herniations cause no symptoms at all.
Recognising the symptoms
Leg pain may be more troublesome than back pain and can feel sharp, burning or electric. It may travel through the buttock and thigh into the calf or foot. Sitting, coughing or sneezing can aggravate symptoms.
You may also notice altered sensation, pins and needles or weakness. Difficulty lifting the front of the foot, known as foot drop, can cause the foot to catch on the ground or make walking more difficult. New or worsening weakness needs urgent medical assessment. Persistent pain that disrupts sleep, walking or work is also a reason to seek specialist advice.
Getting the diagnosis right
A detailed assessment begins with your symptoms, their effect on daily life and an examination of strength, sensation and reflexes. An MRI scan may be appropriate when symptoms persist, weakness develops or the result will help guide treatment. I review the images alongside the examination findings to establish whether the disc abnormality explains your symptoms.
This is particularly important when a scan shows changes at several levels. Distinguishing pain arising from the disc itself from pain caused by an inflamed or compressed nerve helps guide treatment. It also allows a clearer discussion about which symptoms an injection or operation is most likely to improve.
Recovery without surgery
Most people improve without an operation. Symptoms often settle over several weeks as inflammation reduces, and herniated disc material can shrink over time. Recovery varies, so progress and any changes in nerve function should be reviewed. Treatment may include appropriate pain relief, gentle activity and physiotherapy tailored to your symptoms.
Rehabilitation helps you rebuild movement, strength and confidence, with a gradual return to normal activities. Prolonged bed rest is generally unhelpful. Medication should be selected with your medical history and other medicines in mind. If pain remains disabling or recovery stalls, we can review whether an injection or surgery would offer a worthwhile benefit.
Targeted injections for sciatica
For selected patients, particularly those with acute, severe sciatica, an image-guided injection can reduce inflammation around an irritated nerve. A selective nerve root injection or transforaminal epidural places local anaesthetic and corticosteroid close to the affected nerve. Other epidural approaches may be appropriate depending on the symptoms and anatomy.
An injection can provide a period of pain relief that makes sitting, walking, sleeping and rehabilitation easier while recovery continues. The degree and duration of benefit vary. The response can sometimes help clarify which nerve is contributing to the pain. The decision to proceed takes account of your symptoms, imaging and medical history, with a discussion of the expected benefits, limitations and risks.
When surgery can help
Surgery may be appropriate when leg pain remains disabling despite suitable non-operative treatment and the MRI findings match the symptoms. Significant or progressive weakness may justify earlier intervention. Symptoms suggesting cauda equina syndrome require emergency assessment. The usual aim is to remove the disc fragment pressing on the nerve while preserving the remaining disc and supporting structures. This is called a discectomy. Surgery generally offers more predictable relief of nerve-related leg pain than of back pain arising from the disc itself. Spinal fusion is not routinely required for an uncomplicated lumbar disc herniation.
Choosing the right procedure
My practice includes microscopic and endoscopic spinal surgery. The choice of procedure depends on the position of the herniation, your anatomy, any previous surgery and the approach most likely to relieve your symptoms safely.
1 - Microsurgical decompression and microdiscectomy
Microdiscectomy is an established operation performed through a small incision, using a surgical microscope to identify the nerve and remove the compressing disc fragment. Where necessary, a small amount of bone or ligament is also removed to create space around the nerve. This decompression is tailored to the location and extent of the pressure. Microsurgical techniques remain effective options for many types of lumbar disc herniation.
2 - Endoscopic discectomy
Endoscopic surgery uses a small camera and specialised instruments to visualise and treat the disc through a keyhole approach. Depending on the location of the herniation, access may be from the side through the opening where the nerve exits the spine. This is called transforaminal endoscopic lumbar discectomy (TELD).
Alternatively, the disc may be approached from the back between the bony arches of the spine, using an interlaminar approach. Unilateral biportal endoscopy (UBE), uses two small access points: one for the camera and one for the surgical instruments. These techniques aim to preserve surrounding tissues while allowing targeted decompression. Suitability and the expected recovery benefit depend on the individual case.
3 - Transforaminal discectomy with laser disc decompression
Percutaneous laser disc decompression may be considered for certain contained herniations, where the displaced material remains within the outer disc covering. A laser fibre introduced through a needle reduces pressure inside the disc. Careful assessment is essential to determine whether this approach is appropriate for your particular disc herniation.
What to expect during recovery
Many patients can walk on the day of discectomy and go home the same day or after an overnight stay. Leg pain may improve quickly, while numbness and weakness often take longer and may not fully resolve. Return to work, driving and exercise depends on the procedure, your recovery and the demands of your activities.
Follow-up and rehabilitation help guide a gradual return to everyday life. All procedures carry risks. For discectomy, these include a small risk of infection, bleeding, a spinal fluid leak, nerve injury and recurrent disc herniation. Your consultation should explain the likely benefits and the risks relevant to you, alongside the alternatives.
Symptoms that need emergency assessment
Attend A&E immediately if you develop new difficulty starting or passing urine, altered awareness of bladder filling, loss of bladder or bowel control, or numbness around the genitals. Severe or rapidly worsening weakness affecting both legs also needs emergency assessment. These can be warning signs of cauda equina syndrome, a rare but serious compression of the spinal nerves. Do not wait for a routine clinic appointment.
A treatment plan tailored to you
As a Consultant Orthopaedic Spinal Surgeon with a specialist interest in minimally invasive and endoscopic techniques, I offer assessment and treatment for lumbar disc herniation and sciatica.
My priority is to explain what is causing your symptoms and help you choose an appropriate treatment, whether that involves rehabilitation, a targeted injection or surgery. Your treatment plan should reflect the effect of the condition on your life, your nerve function and your goals for recovery.
If sciatica is affecting your daily life, symptoms are persisting despite treatment, or you would like a second opinion on your MRI or proposed surgery, you can book a consultation with Professor Amarjit Anand through his Top Doctors profile.
