The fibrous ring is so hard that it can withstand pressure of up to 20 atmospheres. Normally, the pressure inside our intervertebral discs is similar to the pressure in a car tire.

When the fibrous ring wears down, tears out causing the nucleus pulposus to budge out, this is spinal disc herniation. Hernias are classified into 2 types: common (pic.1) and sequestrated, when hernia breaks off from the disc and has no continuity with it (pic.2).

A herniated disc may be found during clinical neurological and orthopedic examination and by the results of magnetic resonance imaging (MRI).

This is what a large lumbar hernia of one of my patients looks like. Later it disappeared.

Resorption is reduction or complete disappearance of disc herniation without any surgical intervention. In other words, a patient had a herniated disc, but as a result of treatment or due to body defense mechanisms, it disappeared. Let us have a look at this situation on an MRI scan.

On this scan, you can see complete resorption, which means that the disc structure is actually restored. But is it really useful and important for a patient to have herniated disc reduction?

Now let us step aside from a herniated disc for a while and take a broader look at the regeneration process. For better understanding, let us compare resorption with a bone fracture. Further, we are going to use the same comparison as it is very demonstrative and helps to better understand treatment approaches.

Here we should make a brief note about the mechanisms. The nucleus pulposus is foreign to our immune system, and when its fragment gets into the epidural space (this is a space in the spine where hernia migrates to) immune response is triggered because hernia cells come up against the immunity. And the regenerative process is triggered through inflammation.

Nature initially created this smart mechanism. For example, a primitive man had a herniated disc. As a result of this condition, they could not move anymore and died because they were not able to get food. Consequently, such mechanisms are necessary for saving the human race.

There is no easy answer to this question. While some authors say that they observed resorption to happen from 3 to 21 months, the majority come to the conclusion that the average period of resorption is 12-15 months without any stimulating treatment.

Proper treatment and medical screening may reduce this period to 3-6 months.

This difference can be explained by many factors such as the size of a hernia, its degree, location, and patient's condition.

How can we predict the process?

Attention! Any prognosis is based on MRI scans (not MRI description).

Currently, there is several criteria that allow estimating probability and time of resorption. Naturally, MRI should be associated with current deterioration, i.e. it should be done after the pain syndrome occurred and the scans should be done not later than 3 months (preferably, not later than 1 month).

MRI scans show the state of the disc, hernia size, its MRI signal intensity, degree of inflammation of surrounding tissues, state of muscles, and some more parameters. A set of criteria allow to make a prognosis but does not guarantee that resorption will occur because resorption depends on many other factors.

Important:
While it may seem logical (large hernia = severe inflammation), the size of a hernia and how acute is the process are not always interrelated. True, it is often the case, but an old hernia that has not been resorbed under the load continues each time to bulge out. And each time a patient suffers aggravation of the condition and pain like an electric shock.

However, it does not always result in severe inflammation.

For example, in the picture you can see a small protrusion and a sequestrated hernia. A sequestrated hernia has a better chance for resorption but a clinical picture and pain syndrome will be much more severe.

Disc nutrition: Disc has a poor blood supply and disc metabolic processes are very slow. It is a myth that the disc gets nutrition from surrounding muscles. It is not so. All the nutrients are absorbed by diffusion from vertebral bodies and it normally happens during walking. And vertebral bodies receive necessary nutrients from the arteries that branch from the aorta.

Our opinion: Correct tactic doubles the chances for resorption. As for the clinical management of patients with a herniated disc, it is not such a sure thing.

When we say tactic, we do not mean drugs and injections, because a herniated disc is a biomechanical and degenerative condition, so drugs are not our best choice. We would also like to underline the phrase management of a patient.

It is critical to not let the patient make fatal mistakes and manage him helping to overcome the diseases and become healthy.

You suddenly have severe pain, you decided to visit a doctor and did an MRI just in case. Your doctor prescribed you pain medications, myorelaxants (to relax your muscles) and recommended that you should strengthen the core and do gymnastic exercises. Being a responsible patient, you did everything you were told, but the pain is still there. You visit the doctor again.

Now massage or manual therapy is added to the treatment, you still should take the drugs and strengthen your muscles. In case the pain is intolerable, you are recommended an intradiscal injection of Diprospan to alleviate the pain. You agree to do everything because you lost the ability to sleep as a result of pain. 3-4 weeks after you can work, at least. You keep on with the exercises and massage.

This is not the worst scenario, by the way.

Now let us go back to what I have said earlier – acute disc herniation is similar to fracture or trauma.

You need time and rest for the arm to heal. It is necessary for a fracture site to go through all the stages of inflammation. Th swelling will be present but it will reduce; immune cells will migrate to this sire and as a result of very active inflammation, the site may be warm to touch. This is absolutely normal. This is how it should be.

And what if one manipulates the broken arm as I mentioned above?

Well, the union will be delayed or malunion may occur; in the worst-case scenario, it may be nonunion.

So the approach to treating acute (I stress the word acute!) disc herniation should be similar to fracture treatment. This is fundamental for healing and adequate regeneration (resorption) processes.

Acute disc herniation lasts for 4 weeks. During this period you want to avoid certain physical exercises, especially forward bent exercises. Daily home routine is allowed, distance walking is also fine if you feel well.

Some people need detailed explanations about everything, herniated disc is not an exception. Let us play a game "Home and daily routine is not..."

These are all real-life examples. Our patients did each and every of these things and they all had a reason why they could not stop doing it.

There are 2 scenarios, please choose:

This is a very interesting topic. Do we have to treat disc herniation? What type of hernia does require treatment? Can we treat a herniated disc in such a manner to speed up/maintain resorption? When and what should we do?

Shortly, not in all cases.

Now we will explain in more detail: disc herniation is not always accompanied by a pain syndrome. It was proved many times. Research, in which 100 randomly selected people at the age of 30-50 years old took part, showed that almost half of them had disc herniation. However, not all of them reported back pain. It means that the appearance and disappearance of disc herniation is a normal thing and it is not always associated with back pain.

The one that is associated with a typical pain syndrome radiating into the arm or leg and its association with pain is confirmed by medical history and the results of neurological examination. This condition is called radiculopathy when a nerve in the spine is compressed.

In the picture you can see types of lumbar radiculopathy. Those areas where a patient can feel pain are marked in pink.

The question of an accurate diagnosis for back pain remains open. The common diagnosis is still non-specific back pain. However, the results of proper neurological and orthopedic examination almost always may help to find the cause of pain.

Shortly, yes, there is sense if there are clinical findings. In case, pain is caused by facet joint damage, then disc herniation reduction will not bring you any physical or psychological relief. And this research showed a close connection between disc herniation reduction and symptoms alleviation.

Pain management. It is necessary to relieve pain syndrome. Everything that pharmacology can offer may be used from common pain medications to anti-epileptic drugs and antidepressants.

Now almost any pain syndrome can be tolerated due to medications and then regenerative processes will come into the game and the pain will cease.

Resorption is a normal process that leads to healing. We can speed up and stimulate this process by improving blood supply, metabolism, and alleviating acute pain.

While the main aim of this guide is to explain what resorption is, we believe it is important to say a few words about surgical treatment as well.

Absolute indications for surgery:

• Compression of cauda equina spinal roots. (This condition causes numbness of the genital area and muscle weakness)
• Pelvic floor dysfunction (mostly, urinary and fecal incontinence)
• Intractable pain syndrome after adequate long-term treatment.

That is. There are no other absolute indications for surgery.

Operative interventions are often offered to patients without a reasonable basis. On average, the successful outcome of surgeries is 70-90%. The effectiveness of surgeries compared to conservative treatment of patients with a disc herniation in the long-term is equal and does not have any additional advantages. The risk of recurrence after microsurgical treatment is 5-30%.

Narrowing of the spinal canal (stenosis) occurs in 10-30 % of cases. Damage of the upper spinal cord segment occurs in 58% of cases, the secondary stenosis of the spinal cord and the damage of facet joints occur in 45 % of cases. There are also some other complications that can be classified as failed back surgery syndrome.

Summary: surgery is not a is not a silver bullet. In the long-term, conservative treatment may prove even more effective. Surgery should be offered only if medically required and this is a measure of last resort. Any competent neurologist and neurosurgeon is well aware of it.