Herniated Disc and Back Pain: How to Recognize It and When Surgery Is Needed

Back pain (or low back pain) is one of the most common disorders in the population, especially at older ages, and represents one of the main reasons for medical consultation.

It is often automatically associated with the presence of a herniated disc; however, the two conditions are not always related. In fact, many episodes of back pain are not caused by a herniated disc and a herniated disc does not always cause pain.

“A herniated disc is characterized by more specific symptoms than common low back pain particularly by pain that radiates along a limb.

The most characteristic sign is the presence of pain that runs along the arm or the leg. This suggests involvement of a nerve root and is much more indicative of a herniated disc than pain localized only in the back.

Furthermore, depending on how the pain spreads, we can already have a clinical idea of the nerve root involved even before diagnostic and instrumental tests,” explains Dr. Luca.

Does a herniated disc always cause pain?

No. In fact, a little-known aspect is that a herniated disc can be present without causing back pain or other symptoms.

“A herniated disc is not always symptomatic. Pain depends on the degree of mechanical or chemical irritation affecting the nerve root,” the doctor emphasizes.

It can happen that during an acute phase the pain is intense, but over time it decreases while the hernia remains visible on MRI without causing symptoms. This means that the presence of the hernia alone is not enough to decide on treatment: the clinical picture always matters.

Contrary to what many think, a herniated disc is not exclusively a disease of older adults.

“Paradoxically, herniated discs can be more frequent in younger individuals (under 40–50 years old), because the disc retains a greater capacity for extrusion.”

It can therefore appear even at a young age, while in older adults degenerative changes of the spine are more common.

The first step is not an MRI scan, but a specialist clinical evaluation with the general practitioner who may then refer the patient for an orthopedic consultation.

“MRI is not always indicated at the onset of symptoms: a proper clinical evaluation is necessary and is always followed by an initial attempt at conservative management of the symptoms,” the specialist emphasizes.

In most cases the initial treatment is conservative and includes:

• functional rest (avoiding strain but not immobilization);
• anti-inflammatory and pain-relieving drug therapy.

If the pain improves, the patient can gradually return to normal activities without further treatment.

If the pain persists despite medical therapy, the next step may be targeted injections (based on corticosteroids or oxygen-ozone therapy). These allow:

• reduction of inflammation of the nerve root;
• control of pain, favoring the natural resorption of the hernia.

When MRI is indicated for a herniated disc

MRI is indicated:

• only in cases resistant to initial attempts of medical therapy;
• from the early stages when neurological deficit symptoms are present.

Performing the exam earlier often does not change the treatment plan.

The most frequent question from patients is precisely this: "When should a herniated disc be operated on?" Surgery is necessary only in specific situations:

• severe pain that does not respond to conservative treatments (medications, injections);
• neurological deficits (loss of strength or sensitivity);
• sphincter disorders or anesthesia in the perineal area, conditions that must be managed with the greatest care as they may require urgent treatment.

“In the presence of persistent pain, neurological deficits, or sphincter disorders, surgery becomes indicated and, in some cases, urgent. These are therefore a minority of cases: the vast majority of herniated discs are treated without surgery,” explains Dr. Luca.

The most commonly used surgery for herniated disc is microdiscectomy, a minimally invasive technique that allows removal of the herniated fragment with great precision while limiting surgical damage to tissues. The goal of this surgery is:

• to eliminate compression on the nerve;
• to preserve spinal structures while reducing surgical trauma.

Endoscopic discectomy techniques are becoming increasingly popular, allowing even faster short-term recovery with similar medium-term results.

Recovery after surgery for herniated disc is generally rapid. It usually includes:

• a period of about two weeks of limitation of more demanding activities;
• a gradual return to daily life;
• possible rehabilitation at a later stage, if necessary.

“Functional rest does not mean staying in bed, but limiting heavier activities and gradually resuming what the patient is able to do. The patient is guided through a gradual recovery process, avoiding prolonged immobilization,” continues the specialist.

There is a possibility of recurrence, especially in younger individuals, related to the natural structure of the intervertebral disc.

“Younger patients have a greater disc extrusion capacity and therefore also a higher risk of recurrence. For this reason, it is important to follow clinical recommendations and gradually resume activities,” explains Dr. Luca.

There is no absolute prevention. Some factors increase the risk:

• smoking;
• sedentary lifestyle;
• physically demanding jobs.

However, a herniated disc may appear even without an obvious strain: sometimes a simple movement is enough, or the patient may not be able to identify a precise cause that explains the onset of symptoms. An active and healthy lifestyle can reduce the risk, but not eliminate it completely.

A herniated disc is a common condition, but often overestimated. The presence of back pain does not automatically mean having a herniated disc, and even when the hernia is present, in most cases surgery is not necessary.

“The therapeutic pathway is almost always initially conservative: only resistant forms or those with neurological signs require further investigation and, eventually, surgery.”

The correct pathway includes:

• clinical evaluation;
• conservative treatment;
• diagnostic investigations where necessary;
• surgery reserved for selected cases.

“A gradual and personalized approach now allows effective treatment of the condition, avoiding unnecessary tests and ensuring targeted interventions only when truly indicated,” concludes Dr. Luca.