Herniated disc (BSV, nucleus pulposus prolapse, NPP)

Back pain that radiates into the leg or arm can indicate a herniated disc. The task of neurology is to help decide whether conservative measures are still possible or whether surgery is necessary.

What is a herniated disc?

The intervertebral discs lie as elastic buffers between the vertebral bodies of the spine. Inside they consist of the so-called gelatinous core (nucleus pulposus)which acts like a kind of gel cushion. This is surrounded by a hard fibrous ring (annulus fibrosus). With age, the water content and thus the elasticity of the disc decreases. If the fibrous ring gets small cracks as a result, the gelatinous core can bulge outwards. (protrusion). If the gelatinous core breaks through the fibrous ring, a herniated disc occurs. (prolapse).

Due to the high stress caused by body weight, especially when sitting, herniated discs in the lumbar spine (lumbar BSV) are the most common (approx.90%).

What complaints does a herniated disc cause?

The discomfort caused by a herniated disc depends on where it occurs, how large it is and whether nerves or nerve roots are involved. Herniated discs in the lumbar spine often radiate into the back of the leg (sciatica pain, lumbago), in the cervical spine over the shoulder in the arm to the hand. A herniated disc basically has five stages, which do not all have to be passed through in order, but sometimes stages are skipped.

  1. Local pain in the area of the spine
  2. + (additional) with charisma
  3. + Sensory disturbance (tingling, numbness..)
  4. + paralysis
  5. + Bladder and bowel dysfunction

What is the neurologist's job?

The neurologist does not see the herniated disc too much from its "mechanical" side, but checks whether there are "functional disorders or damage" to the nerve root that is pressed by the disc. After in the CT or in the MRI the herniated disc has often already been detected by an imaging procedure, it helps to decide whether conservative or surgical treatment is necessary and whether the herniated disc seen in the imaging procedure is the cause of the pain at all. This is done through the neurological examination and the Electromyogram (EMG).

Not every herniated disc requires surgery - conservative versus surgical measures

Whether surgical or conservative has been evaluated differently for decades. At present, it is assumed that it is primarily the functional disturbance of the nerve that determines whether surgery is necessary. In principle, stages 1-3 (see above) should be treated conservatively, i.e. with physiotherapy, heat treatment, sling table, pain-relieving medication.

However, if there is a clear paralysis or even the stadium 5 in a lumbar disc herniation, for example, a bladder disorder with problems urinating, an immediate operation can not be avoided. Here, a 24-hour window applies , i.e. surgery should be performed within the next 24 hours after the onset of paralysis or bladder dysfunction to avoid permanent failures. In extreme cases this can mean: "on Friday afternoon pictures under the arm and presentation in a neurosurgical or orthopedic clinic".

Other signs that point to an urgent need for action:

  • Accident
  • Osteoporosis and minor trauma
  • Tumor history
  • Infection
  • Weight loss
  • Fever
  • nocturnal aggravation
  • Progressive nerve deficits
  • Decreasing pain and paralysis of muscles
  • Kauda syndrome (sensory disturbance in the genito-anal region and/or micturition disorder (typically urinary retention, overflow bladder, possibly incontinence)