Content

Hernia and acute lumbago are conditions that often go hand in hand with severe back pain, and sometimes with leg pain. They can be so similar that a doctor is unable to make the right diagnosis without MRI. This article explains these pathologies in greater detail, the differences between them, and the relation with chronic back pain. We will conclude with a number of suggestions to recover as quickly as possible and to prevent chronic backache.

Hernia

Hernia means both a rupture and a bulge. In a herniated disc, both conditions are present: there is a rupture (tear) in the intervertebral disc and there is a bulge. Most hernias are located in the lumbar spine:

With a hernia, the disc is ruptured, and the core content may end up outside the disc. A hernia is caused by a tear in the fibrous layer – the annulus – that surrounds the core.

3D view of the disc: to the left without a hernia and to the right with a hernia

Viewed from above, it looks like this (cross section):

The tearing process

The annulus consists of about twenty layers of thin lamellae (less than half a millimetre thick) with thousands of strong embedded fibres.

The annulus consists of about twenty lamellae. Each lamella consists of strong fibres.

Under normal circumstances, the core content cannot penetrate the lamellae, but individual lamella may start to leak. If all the lamellae are leaking and core content has left the disc, it is called a hernia. This is a process, starting with the inner lamella to leak. Then the next one and so on. During this process individual fibres can be ruptured. It may take years for all lamellae to be leaking and a hernia to develop. There is also an intermediate form: the contained hernia. In a contained hernia, the last lamella is not yet torn, but it does protrude and presses on a nerve root.

Acute lumbago

Acute lumbago is characterized by a sudden onset and sharp pain in the lower back. The patient experiences a “shooting” pain in the back, the back muscles become tight and the patient can no longer move the back properly. In many cases, it is no longer possible to stand upright.

Explanation

The fibres in the annulus consist of the same material as ligaments (i.e. collagen connective tissue). Each time fibres start to tear, this is accompanied by the same symptoms as with a torn ankle band: a sudden pain, high stiffness and inability to move normally.

A tear in the annulus – fibres are torn

Further damage is prevented by massively tightening the muscles. This reaction is known as bracing. Acute lumbago may appear as a muscle problem, but it is not.

Important:
Only the initial phase after the fibres are torn is called acute lumbago. If the complaints have not fully disappeared after a few months, it is referred to as chronic lumbago, backache or simply as back pain. 

A subsequent lumbago attack is usually more painful than the previous one. This is because there are more nerves present in the outer layers of the annulus. The farther the tear penetrates into the annulus from the inside to the outside, the more painful it gets.

Difference between acute lumbago and hernia

A hernia occurs when the last lamella is torn and core content has left the disc. 

If fibres get torn, but the last lamella remains intact, it is called acute lumbago during the initial phase. After 3 months it is called chronic lumbago or simply back pain.

With a hernia, core content has ended up outside the disc and may compress nerves. This can cause a sharp pain in the leg or paralyse a muscle. These symptoms are uncommon with acute lumbago.

Patients may suffer from acute lumbago several times before they develop a hernia. Often, this is not recognized as part of the process that may lead to a hernia. Later, a hernia seems to have developed “out of the blue”. 

Chronic back pain

In most cases, chronic back pain does not simply start and stay. It’s a process that often begins with an episode of acute back pain which heals well. It may reoccur after months or years and heal again. But at some point, it will not recover completely. In general, this is what happens:

I    Incorrect use of the back leads to micro-leakages in the annulus
II   Micro-leakages result in extra tension in the fibres
III  A “wrong move” will then be the last push to cause these fibres to tear
IV  Repetition of steps one to three may result in chronic back pain

I  Incorrect use of the back leads to micro-leakages

For the disc to remain in good shape, it needs the right mechanical stimuli. Moving frequently and alternately without overloading is good. Walking is equally healthy. On the other hand, sitting down for long periods of time is bad, especially sitting with your back curved. This will decrease the flexibility of the fibres in the disc and may cause back stiffness.

Lounging on a couch with a curved back strains the disc

Frequent bending down by persons who are not used to bending is another risk. In the same way, a wrong sleeping position may lead to back pain: lying down while your back is twisted will also decrease the flexibility of the fibres in the disc.

If the vertebrae are twisted over a longer period of time, this may lead to stiffness

Due to the decreased flexibility, the disc is less able to absorb forces and the core content may leak into the annulus faster, resulting in micro-leakages. If several lamellae leak, a kind of “pathway” is created in the annulus. This is a weak spot that is vulnerable to overload.

Micro-leakages: the core content starts to leak between the fibres (Tampier, 2007)

II   Micro-leakages result in extra tension in the fibres

The leakage will not simply pass through the lamellae, this process requires a certain amount of force. When the wrong movement stops, the leaking stops as well. As soon as the wrong movement is resumed, the leaking process will continue. The force that pushes the leakage further into the annulus will cause extra tension in the neighbouring fibres.

The tension in the fibres next to the leakage is greater than in other fibres

III  A “wrong move” is the last push

Under normal circumstances, the tension in all fibres is equal. This makes the disc strong and reduces the risk of tears. Micro-leakages increase the tension in some fibres, making these specific fibres vulnerable. These fibres may even tear during normal, natural movements that involve bending and twisting the back. 

The fibres with the highest tension will tear first

This is the classical combination for spraining your back:
Extra tension in the fibres + bending + twisting.
This may occur, for example, when digging in the garden.

IV  Repetition of steps I through III

After a first cycle of steps one to three, internal disc damage (IDD) has occurred. This causes the disc to weaken. Many patients do not change their “incorrect back behaviour”, even if such behaviour makes their backs extra vulnerable. It is not surprising that the cycle will repeat itself: more than 50 percent of all patients will experience another lumbago attack within a year.

The more recurrences, the more damage and the longer the recovery period. This repetitive process may well result in chronic backache. IDD is the most common of all possible causes of back pain.

Recovery and Prevention

There are several possibilities to recover effectively and quickly from lumbago and hernia:

  1. Push the leakage back
    Using special exercises it is often possible to push leakages back into the core. This can reduce the tension in the fibres quickly, resulting in a reduction in pain and other symptoms. For more info, see the book ‘Low Back Pain and Hernia. How to get rid of it!

    Ipel Test
    The Ipel test has been designed by the authors of this book. The aim is to detect
    (micro-) leaks from the core into the annulus. If, during the test, the back can move freely without extra resistance, the test is negative. A positive test result, however, suggests the existence of (micro-) leaks and indicates where they are located in the disc. This also indicates which exercise might be most effective to push the leaked core content back into the core
  1. Take your body signals seriously
    The tearing of the fibres is often preceded by other signs, such as a tired back, stiffness or pain. Please take this seriously: be careful and do the special exercises mentioned under point 1.

  2. Don’t stay seated for long periods, especially with your back bent
    Alternate between sitting, standing and walking. Avoid sitting down with a bent back, at home, at work or when driving a car.

  3. Walk a lot
    Walk several times a day, preferably three or more times, with a total of at least one hour. 
  1. Improve your sleeping position
    Don’t sleep too long with a twisted back or neck, because this is stressful for the fibres in the discs. A body pillow may help to adopt a better sleeping position
  1. Avoid throwing out your back again
    In addition to the measures mentioned above, there are many more options for prevention. See the book Lower Back Pain, Hernia and Acute Lumbago. How to get rid of it. The Ipel test can play a crucial role in this. As soon as you feel your back is becoming “more sensitive” or stiffer, it is wise to perform the test, and if positive, to start practising right away.

Operations

  • In 80 percent of cases, a hernia will disappearby itself within 6 to 8 weeks. The hernia material is absorbed by the body. This is why, in general, no operation is performed during this period. There are a number of exceptions:
  • In the event of uncontrolled loss of urine or stool. Any delay may lead to permanent incontinence. This is called caudaequina syndrome and emergency surgery is necessary.
  • In the event of unsustainable pain that cannot be remedied by medication.
  • In the event of paralysis in the leg, such as foot drop. There is a risk of permanent injury.
  • If private or professional circumstances do not allow any further postponement.

Operations can be performed in the classic way, from the back:

  1. Open operation
  2. Microscopic operation
  3. Micro-tube operation
  4. Endoscopic surgery (inter laminar)

A microscopic operation is considered to be the “gold standard”. Using a 3 cm incision, access to the hernia is gained by loosening the large back muscle from the vertebrae, removing a piece of bone from the vertebral arch, a piece of connective tissue, and a piece of the ligament lying underneath (ligament flavum). 

Another option is to remove a hernia from the side:–   TESSYS (Transforaminal Endoscopic Surgical System).

This is done through an endoscope, with a skin incision of just 8 mm. In the Netherlands this type of operation is known as PTED (Percutaneous Transforaminal Endoscopic Discectomy).

The advantage of this procedure is that it causes less damage. Also, this procedure does not require an overnight stay, unlike operations performed from the back.
For hernias located on the side, foraminal hernias, TESSYS / PTED surgery is the only option, because this location is nearly impossible to reach via the back/rear.

Comparative studies of back and side operations show that both variants are considered to be safe, reliable and effective. Side surgery has fewer complications and patients are usually back on their feet sooner.

Important:

Surgery can remove a hernia (i.e. the bulge) but not the damage present in the disc itself. After surgery, the pain caused by the compression of a nerve often decreases immediately and completely (especially the pain in the leg). However, the back pain resulting from the damaged disc remains in many cases more or less. This is why for chronic back complaints without any signs of nerve compression, surgery is usually not considered. 

Conclusion

Hernia and acute lumbago are strongly related. The anatomical event is largely the same in both conditions: torn collagen fibres. This does not ‘just happen’: it is often preceded by ongoing processes, such as the leakage of core content into the annulus. In many cases, these leakages can be reduced. To promote a quick recovery and prevent recurrence, it is important to reduce those leakages as soon as possible with the help of special exercises. The Ipel Test can be a useful tool to help achieve this.
The more often a person throws out their back, the more disc damage will occur, and the more difficult it will be to recover from it. This may result in chronic backache.

Justification

The reduction of leakages is hardly known among doctors and therapists. However, it has been demonstrated using both laboratory research and experimental research. After the publication of the first Dutch edition of their book, Menno Iprenburg and Jan Willem Elkhuizen developed a test to detect potential leakages. This Ipel test has been implemented in the 6e edition of the Dutch version of this book, and in the first edition from the English version.

For more information, more exercises and many tips, see the book:

Lower Back Pain, Hernia and Acute Lumbago
How to get rid of it!