Disc Herniation

Original Editors Fauve simoens, Nele Postal

Top Contributors - Lucinda hampton, Chelsea Mclene, Andeela Hafeez, Fauve simoens, Admin, Liesa Rodet, Kim Jackson, Nele Postal, Mariam Hashem, Teugels Amber, Rachael Lowe, Simisola Ajeyalemi, Laura Ritchie, Kai A. Sigel, Fien Van Buggenhout, Evan Thomas, Lisa De Donder, Ellen Wynant, Lara Lagrange, Tony Lowe, Uchechukwu Chukwuemeka and Jess Bell

Definition/Description

The herniation process begins from failure in the innermost annulus rings and progresses radially outward. The damage to the annulus of the disc appears to be associated with fully flexing the spine for a repeated or prolonged period of time. The nucleus loses its hydrostatic pressure and the annulus bulges outward during disc compression. [1]
A herniated disc can irritate the nerves and results in pain, tingling, stiffness and weakness in an arm or leg. But many people experience no symptoms from a herniated disc. (40 LOE 5)

Other names used to describe this type of pathology are prolapsed disc, herniated nucleus pulposus and discus protrusion. (34 LOE 2A) (35 LOE 2B) (37 LOE: 2B)

Herniated disc video(40 LOE 5)

Clinically Relevant Anatomy

There are many structures surrounding a discus intervertebralis: annulus fibrosus, anterior longitudinal ligament, posterior longitudinal ligament, nerve roots, nerves and muscles. A discus herniation can cause mechanical irritation of these structures which in turn can cause pain. This is presented as low back pain with possible radiculopathy if a nerve is affected.

In the lumbar region, the level at which a disc herniates does not always correlate to the level of nerve root symptoms. When the herniation is in the posterolateral direction the affected nerve root is the one that exits at level below the disk herniation. This is because the nerve root at the hernia-level has already exited the transverse foramen. A foraminal herniation on the other hand affects the nerve root that is situated at the same level.

In the cervical region the herniated disc compresses the nerve actually exiting at that level.

There are four types of herniated discs described in Clinical Anatomy and Management of Back Pain (2006):

Bulging:extension of the disc margin beyond the margins of the adjacent vertebral endplates

Protrusion:the posterior longitudinal ligament remains intact but the nucleus pulposus impinges on the anulus fibrosus

Extrusion:the nuclear material emerges through the annular fibers but the posterior longitudinal ligament remains intact

Sequestration:the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space

Epidemiology /Etiology

Disc herniations are often asymptomatic, and 75% of the intervertebral disc herniations recover spontaneously within 6 months. In 95% of the lumbar disc herniations the L4-L5 and L5-S1 discs are most commonly affected. The cervical disc herniations are most locate at level C5-C6 and C6-C7. 

The most common direction for a disc herniation to occur is in the posterolateral direction, where the annulus fibrosis is thin and not supported by the anterior or posterior longitudinal ligament.   Chronic or sudden forcible hyperflexion or torsion can cause a disc hernia, but mostly there are no specific inciting events. Other possible causes can be a whiplash, poor posture, obesity smoking and occupational risks such as driving for a long time.

Characteristics/Clinical Presentation

Symptoms differ greatly depending on the position and the size of the herniated disc. If the herniated disc is not pressing on a nerve it is possible that the patient will experience no pain at all. When it’s pressing on a nerve, there may be a sharp pain, stiffness, tingling or weakness in the area of the body to which the nerve travels. (15),(6 LOE:5)
A herniated disc in the lumbar spine causes pain, burning, tingling and stiffness that radiates from the buttock into the leg and sometimes into the foot. It’s called sciatica.
See:http://www.physio-pedia.com/Sciatica
It may be more severe with standing, walking or sitting. Along with the leg pain, the patient may experience low back pain. (15), (5 LOE:5), (6 LOE:5)
A herniated disc in the cervical spine may include dull or sharp pain in the neck or between the shoulder blades, pain that radiates down the arm to the hand or fingers, or numbness or tingling in the shoulder or arm. The pain may increase with certain positions or movements of the neck. (15), (6 LOE:5)

Differential Diagnosis

• • Mechanical pain
  See: http://www.physio-pedia.com/Non_Specific_Low_Back_Pain
  • Discogenic pain(42 LOE2A)
  ◦ Symptoms: mainly low back pain
  • Myofascial pain(42 LOE2A)
  ◦ Symptoms: local and/or referred pain, sensory disturbances
  • Spondylosis/spondylolisthesis
  See: http://www.physio-pedia.com/Spondylolysis
  http://www.physio-pedia.com/Spondylolisthesis
  • Spinal/ lumbar stenosis(42 LOE2A)
  ◦ Symptoms: mild low back pain, multiradicular pain in one or both legs, mild motor deficits
  ◦ See: http://www.physio-pedia.com/Spinal_Stenosis
  • Cyst (42 LOE2A)
  ◦ symptoms: sensory disturbances, occasionally motor deficits
  • Hematoma(42 LOE2A)
  ◦ diagnosis by CT-scan
  • Discitis/osteomyelitis
  • Mass lesion/malignancy/neurinomas(42 LOE2A)
  ◦ difficult diagnosis when tumor is small in size
  ◦ symptoms: pain in hip and or thigh, atrophy of glutei en thigh muscles
  • Myocardial infarction
  • Aortic dissection(42 LOE2A)
  ◦ Aneurysm (aortic, iliac, abdominal)
  ◦ symptoms: low back pain, located leg pain
  
• 
  

Diagnostic Procedures

Physical examination
Straight_Leg_Raise_Test: The SLR test is a test done during the physical examination.This test is a very accurate predictor of a disk herniation in patients under the age of 35. For further explanations see: Straight Leg Raise test (35 LOE:2B)
Imagining
Imaging can be used to reveal disc herniations[2], note that most disc herniations are asymptomatic:
Plain X-rays don't detect herniated disks, but they may be performed to rule out other causes of back pain, such as an infection, tumor, spinal alignment issues or a broken bone. A CT-scan creates cross-sectional images of your spinal column and the structures around it. (6 LOE:5)
MRI Scans This test can be used to confirm the location of the herniated disk and to see which nerves are affected
Myelogram A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on your spinal cord or nerves due to multiple herniated disks or other conditions. (6 LOE:5)
Nerve tests Electromyograms and nerve conduction studies measure how well electrical impulses are moving along nerve tissue. This can help pinpoint the location of the nerve damage. (6 LOE:5)

Outcome Measures

If the disc herniation is symptomatic different outcome measures can be used:
Short Form-36 bodily pain (SF-36 BP)
Physical function scale (PF scores)
Oswestry disability index
Roland-Morris disability index
VAS-score

north american spine society score for neurologic symptoms

Examination

See cervical or lumbar radiculopathy for the examination that can be used to assess if the radiant pain is caused by disc herniation.

Physical examination of lumbar radiculopathy due to disc herniation: (28 LOE 1A) (29 LOE 5)
• Straight Leg Raise (SLR); specificity (0,89) and sensitivity (0,52) (35 LOE 2B) (39 LOE:4)
• Forward flexion test
• Hyper-extension test
• Slump test; specificity (0,83) and sensitivity (0,84) (24 LOE 1A)(39 LOE:4)
• Manual muscle testing
• Sensory testing
• Supine straight leg raise
• Lasegue’s sign
• Crossed Lasegue’s sign (25 LOE 1B)

Medical Management

Over-the-counter pain medications. If your pain is mild to moderate, your doctor may tell you to take an over-the-counter pain medication, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others).
Narcotics. If your pain doesn't improve with over-the-counter medications, your doctor may prescribe narcotics, such as codeine or an oxycodone-acetaminophen combination (Percocet, Oxycontin, others), for a short time. Sedation, nausea, confusion and constipation are possible side effects from these drugs.
Nerve pain medications. Drugs such as gabapentin (Neurontin, Gralise, Horizant), pregabalin (Lyrica), duloxetine (Cymbalta), tramadol (Ultram) and amitriptyline often help relieve nerve-damage pain. Because these drugs have a milder set of side effects than do narcotic medications, they're increasingly being used as first line prescription medications for people who have herniated disks.
Muscle relaxers. Muscle relaxants may be prescribed if you have muscle spasms. Sedation and dizziness are common side effects of these medications.
Cortisone injections. Inflammation-suppressing Therapeutic Corticosteroid Injection may be given directly into the area around the spinal nerves. Spinal imaging can help guide the needle more safely. Occasionally a course of oral steroids may be tried to reduce swelling and inflammation.

A very small number of people with herniated disks eventually need surgery. Your doctor may suggest surgery if conservative treatments fail to improve your symptoms after six weeks, especially if you continue to experience:

• Numbness or weakness
• Difficulty standing or walking
• Loss of bladder or bowel control

In many cases, surgeons can remove just the protruding portion of the disk. Rarely, however, the entire disk must be removed. In these cases, the vertebrae may need to be fused together with metal hardware to provide spinal stability. Rarely, your surgeon may suggest the implantation of an artificial disk.

Surgical Treatment

Only a small percentage of patients with lumbar disk herniations require surgery. Spine surgery is typically recommended only after a period of nonsurgical treatment has not relieved painful symptoms. Patients with sciatica due to a lumbar herniated disc are beneficial to early surgery. There is evidence for a better short-term relief of leg pain compared to conservative therapy. (23 LOE 1A) Patients with a lumbar disc herniation have a greater improvement after surgery than non-operatively patients. (27 LOE 2C)
The most common surgical procedure for a herniated disk in the lower back is a lumbar microdiskectomy. Microdisketomy involves removing the herniated part of the disk and any fragments that are putting pressure on the spinal nerve.[9]

Physical Therapy Management

Physical therapy often plays a major role in herniated disc recovery. Its methods not only offer immediate pain relief and decreases disability (26 LOE 1B), but they also teach you how to condition your body to prevent further injury.(10, LOE:5) No evidence has been found for the effectiveness of conservative treatment compared with surgery for treatment of cervical disc herniation. (22) Microdiscectomy for management of lumbar disc herniation in patients with associated radiculopathy is more effective than conservative management. There is moderate evidence that favours stabilization exercise over no treatment, manipulation over sham manipulation and the addition of mechanical traction to medication and electrotherapy. There was no evidence found for traction, laser or ultrasound. (24 LOE 1A) Conservative treatment has been compared with a surgical treatment (lumbar discectomy) regarding return to sport by athletes. No significant difference has been found the two groups of treatment, but the athletes no longer perform at the prior level of participation in both groups. (26 LOE 1B)

Many studies have shown that a combination of different techniques will form the optimal treatment. Exercise and ergonomic programs should be considered as important components of the therapy.(34 LOE 2A)

Deep Tissue Massage: There are more than 100 types of massage, but deep tissue massage is an ideal option if you have a herniated disc because it uses a great deal of pressure to relieve deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.

Hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results.
Your physical therapist may use heat to increase blood flow to the target area. Blood helps heal the area by delivering extra oxygen and nutrients. Blood also removes waste byproducts from muscle spasms.10 LOE:5)
Conversely, cold therapy (also called cryotherapy) slows circulation. This reduces inflammation, muscle spasms and pain. Your physical therapist may place an ice pack on the target area, give you an ice massage, or even use a spray known as fluoromethane to cool inflamed tissues.

Hydrotherapy: As the name suggests, hydrotherapy involves water. As a passive treatment, hydrotherapy may involve simply sitting in a whirlpool bath or warm shower. Hydrotherapy gently relieves pain and relaxes muscles.

Transcutaneous electrical nerve stimulation (TENS): A TENS machine uses an electrical current to stimulate your muscles. It sounds intense, but it really isn't painful. Electrodes taped to your skin send a tiny electrical current to key points on the nerve pathway. TENS reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body's natural pain killers.

Traction: The goal of traction is to reduce the effects of gravity on the spine. This technique is often used to relief the patient’s pain in order to facilitate the progression to an exercise program. (34 LOE 2A)
By gently pulling apart the bones, the intent is to reduce the disc herniation. The analogy is much like a flat tire "disappearing" when you put a jack under the car and take pressure off the tire. It can be performed in the cervical or lumbar spine.[14] Lumbar traction may be performed in prone position as in supine position. When applying this kind of treatment, it is recommended to place the patient in a flexed position as it tends to open the neuroforamin and to stretch the posterior elements of the back. To unload the intervertebral disc more effectively it is preferable to let the patient lay in a prone position with a correct amount of lordosis in the lower back.
Usually traction will be performed with a force equal to 50% of the patient’s body weight. The total duration of the treatment should be 15 minutes with use of an intermittent force pattern of 20 to 30 seconds on and 10 to 15 seconds off. (34 LOA 2A)
A recent study has shown that traction therapy has positive effects on pain, disability and SLR on patients with intervertebral disc herniation.(35 LOE 2B)

Core stability: Many people don't realize how important a strong core is to their spinal health. Your core (abdominal) muscles help your back muscles support your spine. When your core muscles are weak, it puts extra pressure on your back muscles. Your physical therapist may teach you core stabilizing exercises to strengthen your back.
A core stability program decreases pain level, improves functional status, increases health-related quality of life and static endurance of trunk muscles in lumbar disc herniation patients. Core stability exercises could be performed in water as well, there is no difference between the environments (land or water). (31 LOE 3B)
See: http://www.physiopedia.com/The_effectiveness_of_core_stability_exercise_with_regards_to_general_exercise_in_the_management_of_chronic_non_specific_low_back_pain - Core_Stability

Flexibility: Learning proper stretching and flexibility techniques will prepare you for aerobic and strength exercises. Flexibility helps your body move easier by warding off stiffness(10 LOE:5)

Muscle strengthening: Strong muscles are a great support system for your spine and better handle pain

Lumbar stabilizing exercises: (LSE) (16 LOE 2A) (36 LOE 3B)
There is evidence that SLE increases lumbar stability and improve ADL activity in patients with lumbar disc herniation.
Exercises

LSE reduces the pain intensity and improves the functional capacity in young male patients with lumbar disc herniation.

Note: See ‘Rehabilitation interventions with postoperative lumbar disc hernia’ for further explanation and examples of LSE.
See: http://www.physio-pedia.com/Exercises_for_Lumbar_Instability

TCM: Traditional Chinese Medicine for low back pain (17 LOE 1B,18 LOE 1B)
- has been demonstrated to be effective Reviews have demonstrated that acupressure, acupuncture and cupping can be efficacious in pain and disability for chronic low back pain included disc herniation.
- Acupressure
- Cupping

Spinal manipulative therapy (SMT) and mobilization (MOB) (19 LOE 1A) Acute low back pain short-term pain relief
Chronic low back pain, SMT has an effect similar to NSAID.
See: http://www.physio-pedia.com/Spinal_Manipulation

Rehabilitation interventions with postoperative lumbar disc hernia
The first thing to do when patients come out of the surgery, is to give information about the rehabilitation program they will follow the next few weeks. The patients are instructed and accompanied in daily activities such as: coming out of bed, going to the bathroom and clothing. Besides all this the patients have to pay attention on the ergonomics of the back throughout back school. [11][12][13][14]

An immediate rehabilitation program is recommended in patients with microiskectomy. Exercise therapy with a cognitive intervention is an effective treatment. This treatment is considered as an alternative to vertebral fusion in patients who underwent LDH surgery with symptom recurrence after the first surgery. (21) Patients who participated in a comprehensive rehabilitation program after lumbar disc herniation surgery have better long-term health benefits than those who didn’t follow any intervention, but this can not be superior to ham therapy. (25 LOE 1B)

Most studies start their rehabilitation program 4-6 weeks postsurgery. In the meantime, the patients were followed on the above mentioned instructions.[14] Unlike, the most important goals of the rehabilitation of other peripheral joints, namely: regaining strength and range of motion; the most important goal of the rehabilitation of the low back is to improve the patients’ health. Regaining strength and range of motion are commonly used wrong as most important goals of the low back rehabilitation because of the influence from the athletic world and sport rehabilitation. These goals increase the risk for more back problems. [1]

During back rehabilitation of postoperative disc hernia it is important to regain core stability first. The ‘corset‘ of the lumbar spine -formed by the abdominal and back muscles- has to be rebuild. Maintaining this corset is important during various movements, activities and several situations. [11][12][1][13][14] Keeping this in mind it is self-evident that the endurance of these muscles has to be trained too. Endurance of the muscles participating in the core stability is educated in a neutral position of the upper body/back due to start with short term repetitions that shift into long term repetitions. The exercises that are given in the beginning are subsequently performed in different positions and with several arm and leg movements.[1][13]

Examples of these exercises are dynamic lumbar stabilization exercises which include techniques such as dynamic abdominal girdle and methods for finding and maintaining neutral lumbar position during daily activities. The emphasis is here placed on the multifidus and the transversus abdominis muscle. The multifidus plays a role in the protection of the lumbar region against involuntary movements and torsion forces as it contributes to spine stabilisation. On the other side the transversus abdominis assists to lumbar stability through increased abdominal pressure by acting like a belt around the abdomen. (37 LOE 2B)

Following program can be used as a protocol for rehabilitation following a lumbar microdisectomy: (37 LOE 2B)
▪ Duration of rehabilitation program: 4 weeks
▪ Frequency: every day
▪ Duration of one session: approximately 60 minutes
▪ Treatment: dynamic lumbar stabilization exercises + home exercises
▪ Exercises:
Prior to the DLS training session patients are provided with instruction or technique to ensure and protect a neutral spine position. During the first 15 minutes of each session stretching of back extensors, hip flexors, hamstrings and Achilles tendon should be performed.
DLS consists of:
- Quadratus exercises
- Abdominal strengthening
- Bridging with ball
- Straightening of external abdominal oblique muscle
- Lifting one leg in crawling position
- Lifting crossed arms and legs in crawling position
- Lunges

Home exercises should be added to the treatment. These should be performed every day.
▪ Modalities: 5 repeats during the first week up to 10-15 repeats in the following weeks

Other examples of lumbar stabilization and dynamic lumbar strengthening exercises: (38 LOE 2A)

On the other side, a study has been conducted to analyse the effect of an aerobic training program on post-operative patients. One month after the surgery, the patients received a supervised treadmill exercise next to the home exercise program. The treadmill exercise consisted of a walk of 30 minutes on the treadmill without inclination five times a week with tolerated speed during four weeks. The speed of walking was increased once the patient’s tolerability was considered as high enough. The conclusion is that aerobic exercise-based rehabilitation program in combination with home exercises starting one month after first-time single-level lumbar microdiscectomy has a positive effect on functionality than only a home exercise program. However the authors of the study point out that more studies should be conducted concerning aerobic exercise programs in post-operative patients. (41 LOE: 2B)

A few studies mention stretching of shortened muscles, such as Hamstrings and Quadriceps. [11][12] Hip flexion restriction seems not to be linked with any back pain and maybe unnecessary if the goal is just solving back problems. Eventually if Hamstrings and Quadriceps are shortened, restricted functioning of the hip may occur. For this reason, stretching is necessary to regain full function of the hip. [1]
If core stability is totally regained and fully under control, strength and power can be trained. But only when this is necessary for the patients functioning/activities. This power needs to be avoided during the core stability exercises because of the combination of its two components: force and velocity. This combination forms a higher risk to gain back problems and back pain. [1]
Various studies have shown that a treatment with accompaniment of a physical therapist or a multi-disciplinary treatment have a positive effect on the regularity of doing the exercises and the rapidity of return-to-work. [11][13][14] A high intensity program gains faster results as a low intensity program, but the results are the same in the end.[13] During the rehabilitation the patients have to be supported to restart and preserve their daily activities; active coping has to be stimulated. Guiding and instructing the patients are of great importance during the treatment/rehabilitation. [11][1][14]

Resources

http://www.isass.org/h/patient_resources_spine_conditions.html

http://orthoinfo.aaos.org/topic.cfm?topic=a00534

https://my.clevelandclinic.org/health/diseases_conditions/hic_Herniated_Disc

https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf

Recent Related Research (from Pubmed)


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References

see adding references tutorial.

1. 1 McGill, S. (2007). Low Back Disorders: Evidence Based Prevention and Rehabilitation, Second Edition. USA: Human Kinetics.
   2 Lena Shahbandar and Joel Press. Diagnosis and Nonoperative Management of Lumbar Disk Herniation.fckLROperative Techniques in Sports Medicine, 2005; 13: 114-121
   3 L. G. F. Giles et al.The Clinical Anatomy and Management of Back Pain. Butterworth-Heinemann, 2006.
   4 Pradeep Suri et al. Inciting events associated with lumbar disc herniation.fckLRThe Spine Journal, 2010; 10: 388–395
   5 John P. Revord, MD;Typical symptoms of a herniated disc.; 19/1/2015; Spine Health
   Level of evidence: 5
   6 Mayo clinic staff. Herniated disk. 28/01/2014
   Level of evidence: 5
   7 Wayne Moschetti et al. Treatment of Lumbar Disc Herniation: An Evidence-Based Review.fckLRSeminars Spine Surgery, 2009; 21: 223-229
   8 ↑https://www.duo.uio.no/bitstream/handle/10852/28055/dravhandling-haugen.pdf?sequence=3
2. 9 Herniated disk in the lower back. ; American Academy of Orthopaedic surgeons.; November 2012
   10 Jason M. Highsmith, MD.; Physical therapy for herniated discs; 11/06/15; spine universe
   Level of evidence: 5
   11 Ann-Christin Johansson, S. J. (2009). Clinic-based training in comparison to home-based training after first-time lumbar disc surgery: a randomised controlled trial. Eur Spine Journal , 398-409.
   12 Cele B. Erdogmus, K.-L. R. (2007 Vol.32 Nr.19). Physiotherapy-Based Rehabilitation Following Disc Herniation Operation. Spine , 2041-2049.
   13 Mustafa Filiz, A. C. (2005). The effectiveness of exercise programmes after lumbar disc surgery: a randomised controlled trial. Clinical Rehabilitation, 4-11.
   14 Raymond W. J. G Ostelo et al. (2009). Rehabilitation After Lumbar Disc Surgery: An update Cochrane Review. Spine Vol. 34 Nr. 17, 1839 - 1848.
   15 Herniated disc. American Association of Neurological Surgeons. July 2014
   Level of evidence 5
   16 Bakhtiary H. A. et al., Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation, Journal of back and musculoskeletal rehabilitation 18, p. 55- 60, 2005
   Level of evidence 2A
   17 Yuan Q. et al., Traditional Chinese Medicine for Neck Pain and Low Back Pain: A systematic review and meta-analysis, open access article, feb 2015
   Level of evidence 1B
   18 Yuan W. et al, Integrative TCM conservative therapy for low back pain due to lumbar disc herniation: a randomized controlled clinical trial, Evidence-Based Complementary and Alternative Medicine, volume 2013
   Level of evidence 1B
   19 Bronfort G. et al, Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis, The spine journal, volume 4, May 2004, p 335-356
   Level of evidence 1A
   20 /
   21 Santana-Rios JS et al. Postoperative treatment for lumbar dics herniation during rehabilitation. Systematic review, Acta Ortopédica Mexicana, 2014; 28, 2: 113-24.
   Level of evidence: 1A
   22 Gebreariam L. et al. Evaluation of treatment effectiveness for the herniated cervical disc: systematic review. Spine, 2012;15,37: 109-18.
   Level of evidence: 1A
   23 Wilco C.H. Jacobs et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematics review, 2010; 20, 4: 513-522. Level of evidence: 1A
   24 Hahne A.J. et al. Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review, Spine, 2010; 15, 35: 488-504. Level of evidence: 1A
   25 Ebenbichler G.R. et al. Twelve-year follow-up of a randomized controlled trial of comprehensive physiotherapy follow disc herniation operation, Clinical Rehabilitation, 2015; 29, 6: 548-60.
   Level of evidence: 1B
   26 Filiz M et al. The effectiveness of exercise programmes after lumbar disc surgery: a randomized controlled study, 2005; 19, 4: 4-11.
   Level of evidence 1B
   27 Lurie J.D. et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial, 2014; 39, 1: 3-16
   Level of evidence: 2C
   28 Van der Windt et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Systematic Review, 2010; 17, 2.
   Level of evidence: 1A
   29 North American Spine Society. Clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine Society, 2012.
   Level of evidence: 5
   30 Reiman M.P. et al., Return to sports after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis. British Journal of Sports Medicine, 2015.
   Level of evidence: 1A
   31 Bayraktar D et al., A comparison of water-based and land-based core stability exercises in patients with lumbar disc herniation: a pilot study. Disability and Rehabilitation. 2015 Sep 2:1-9.
   Level of evidence 3B
   32 Ye et al.,Comparison of lumbar spine stabilization exercise versus general exercise in young male patients with lumbar disc herniation after 1 year of follow-up. Int J Clin Exp Med. 2015 Jun 15
   Level of evidence 3B
   33 Choi et al., Influences of spinal decompression therapy and general traction therapy on the pain, disability, and straight leg raising of patients with intervertebral disc herniation. J Phys Ther Sci. 2015 Feb
   Level of evidence: 3B
   34 Olson K., Manual Physical Therapy of Spine, Saunders Elsevier, 2009, p114-116.
   Level of evidence: 2A
   35 Jioun Choi MS., Influences of spinal decompression therapy and general traction therapy on the pain, disability, and straight leg raising of patients with intervertebral disc herniation, J Phys Ther Sci. 2015 Feb; 27(2): 481–483.
   Level of evidence: 2B
   36 Ye et al., Comparison of lumbar spine stabilization exercise versus general exercise in young male patients with lumbar disc herniation after 1 year of follow-up. Int J Clin Exp Med., 2015 jun 15
   Level of evidence 3B
   37 Demir S., Effects of dynamic lumbar stabilization exercises following lumbar microdiscectomy on pain, mobility and return to work. Randomized controlled trial., Eur J Phys Rehabil Med. 2014 Dec;50(6):627-40. Epub 2014 Sep 9.
   Level of evidence: 2B
   38 Moon HJ., Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain, Ann Rehabil Med. 2013 Feb;37(1):110-117. English.
   Level of evidence: 2A
   39 Javid MD et al, The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation, Journal of clinical rheumatology, april 2008, pp 87-91
   Level of evidence: 4
   40 Ullrich P.F., orthopedic surgeon, herniated disc, www.spine-health.com, feb 2015 Level of evidence: 5
   41 Gencay-can A., The effect of early aerobic exercise after single-level lumbar microdiscectomy: a prospective, controlled trial, EURJ Phys Rehabil Med 2010;46 – 489-95
   Level of evidence: 2B
   42 Postacchini, F. et al., Lumbar Disc Herniation, SpringerWienNewYork, 1999, p. 293-314,
   Level of evidence 2A