Many people have back pain that keeps on returning. Usually it is hard to say what the exact cause is. But if you have pain that radiates down your leg and into your foot, it may be a sign of a slipped spinal disc, or “herniated disc.”

The spinal discs are found between the vertebrae bones in the spine. They have an elastic casing made of cartilage and a gel-like center (nucleus pulposus). A slipped disc occurs if the spinal disc tissue pushes out, or "herniates," between the vertebrae. This herniated tissue may put pressure on the spinal nerves and irritate them.

A slipped disc can be very unpleasant. But the good news is that the symptoms usually go away on their own within less than six weeks in most people with this problem. And not every slipped disc is painful.

It is estimated that 1 to 5% of all people will have back pain caused by a slipped disc at some point in their lives. Slipped discs are more common in people over the age of 30, and are about twice as common in men as they are in women.

In most people, slipped discs are the result of wear and tear. Over the years, the spinal discs lose their elasticity: Fluid leaks out of them and they become brittle and cracked. These changes are a normal part of the aging process – which varies from person to person, though. Very rarely, an accident or severe injury might also cause damage to a spinal disc and leave it herniated.

Spinal discs act as shock absorbers between the vertebrae in our spine. If a spinal disc is no longer able to bear the strain, it can result in a slipped disc. The associated pain probably arises when part of the spinal disc pushes against a nerve in the spinal cord.

When herniated disc tissue irritates a nerve root in the region of the lumbar spine (lower back), it often causes typical sciatic pain. The nerves that run through the spinal canal connect to the sciatic nerve at the pelvis. The sciatic nerve then runs down the legs. As well as being painful, an irritated sciatic nerve can also cause pins and needles and numbness.

Doctors categorize slipped discs by severity:

• Prolapse: The disc bulges out between the vertebrae, but its outermost layer is still intact.
• Extrusion: There is a tear in the outermost layer of the spinal disc, causing spinal disc tissue to spill out. But the tissue that has come out is still connected to the disc.
• Sequestration: Spinal disc tissue has entered the spinal canal and is no longer directly attached to the disc.

These categories reveal little about what symptoms occur or how severe they might be. But knowing what type of slipped disc someone has is important for the choice of treatment and understanding how the condition might go on to develop.

A slipped disc can cause very sudden and severe shooting pain. If it occurs in the neck area, the pain might radiate into the arms. Slipped discs in the lumbar (lower back) region are the main cause of sciatica. Sciatica is pain that radiates down one leg and into the foot. As well as the typical radiating pain, a slipped disc can also lead to pain in the low back region.

In rare cases, numbness in the buttocks or signs of paralysis may develop in addition to the pain. These symptoms are signs of a more serious problem, like nerve damage. If it affects the function of the bladder or bowel, immediate treatment is needed. That is called "cauda equina syndrome" (CES), and is a medical emergency.

But a slipped disc doesn't always lead to noticeable symptoms. This can be seen in studies in which adults who didn't have back pain were examined using magnetic resonance imaging (MRI): More than 50 out of 100 of them had a bulging (herniated) spinal disc. About 20 out of 100 had a spinal disc that was already quite damaged or even had tissue coming out of it, without causing any symptoms.

Doctors are usually able to determine what is causing acute back pain by asking a few questions and performing a physical examination. X-rays aren't very suitable for diagnosing a slipped disc because they don't say much about the situation: A lot of people who are found to have spinal disc damage on x-ray images don't have any symptoms. Other imaging techniques such as magnetic resonance imaging (MRI) are only rarely needed, if any of the following occur:

• Numbness or paralysis in one or both legs
• Impaired function of the bladder or bowel
• Unbearable pain despite treatment
• Severe symptoms remain for many weeks despite treatment
• Another condition is thought to be causing the pain, for example a tumor

So there are often good reasons why doctors don't suggest doing any complex diagnostic examinations at first if you have back pain: Imaging techniques may show a supposed cause of back pain that actually has nothing to do with the symptoms. This kind of misdiagnosis can then result in unnecessary treatment that may itself be harmful.

Even severe sciatic pain can go away on its own after a while. Until it does, various kinds of pain relief treatment can help to cope with the symptoms. The aim is to stay as active as possible. But treating the pain doesn't speed up your recovery. Most of the work is usually done by the body itself.

If severe sciatic pain caused by a slipped disc lasts longer than six weeks, surgery may be an option to try to relieve the pressure on the affected nerve. Surgery is also always done if the nerves are so severely affected that the bladder or the bowel is no longer functioning properly or certain muscles have become very weak. But that is rare.

Most people with a slipped disc in the lumbar region of their spine (lower back) are offered “conservative” treatment, meaning that the treatment does not involve surgery. This mainly involves exercise, relaxation and positioning, painkillers or local anesthetics, and manual and physical therapy.

Some slipped discs don't cause any symptoms, whereas others lead to severe back pain. A slipped disc in the lumbar region of the spine (the lower back) can press on the sciatic nerve and cause pain that often radiates down one leg and into the foot. Most people recover from a slipped disc within six weeks without treatment. Until then there are a number of treatment options that aim to help relieve the pain and improve mobility.

Exercise, relaxation and positioning

In the past, people who had a slipped disc were typically advised to stay in bed for one to two weeks. Nowadays the opposite approach is taken: people are advised to stay active instead. This is because remaining in a lying position for a long time can make muscles and bones weaker, which can end up causing other problems.

Studies have shown that physical activity can improve mobility. However, whether people keep up with exercise or rest instead wasn't found to influence the back pain itself. So it is a good idea to try to carry out your normal daily activities as much as the pain allows. Exercise has also been proven to effectively prevent back pain from returning.

Relaxation exercises may also be worth a try to help relieve back pain. How you perceive pain and how well you cope with it can be influenced by your mind.

If the pain is very severe, though, there is sometimes simply no other way to deal with it than to lie down and find a position that puts as little strain on your back as possible. Many people find the "psoas" position comfortable: While lying on your back, you put your lower legs on a raised platform high enough so that your knees are bent at a 90-degree angle. But it is important not to stay inactive for too long.

Medication for the pain

There are a number of different medications for the relief of sciatic nerve pain (sciatica) caused by a slipped disc. Most of these are painkillers, but you can also use muscle relaxants and anti-inflammatory drugs. The following medications are the most commonly used. They are all available without a prescription when taken at a low dose:

• Non-steroidal anti-inflammatory drugs (NSAIDs): These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen and naproxen. They have a pain-relieving and anti-inflammatory effect.Because NSAIDs prevent blood from clotting to an extent, they can cause bleeding. The bleeding may be mild, such as a nosebleed or bleeding gums, but more serious bleeding can sometimes also occur, for example in the stomach or bowels. In some cases NSAIDs cause stomach ulcers, too. NSAIDs may also impair the function of the kidneys. If you have asthma, a cardiovascular disease, or a stomach ulcer, you should ask your doctor for advice before taking NSAIDs. NSAIDs can also be injected into muscle tissue, although that is generally not done anymore nowadays. NSAID injections probably don't have any advantages over tablets or suppositories, but they may cause nerve damage, bleeding or inflammation at the site of injection.
• Acetaminophen (paracetamol): Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. For this reason, adults should follow the information on the package insert and make sure they do not take more than 4 grams (4,000 milligrams) of acetaminophen per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.

Some of the medication options have to be prescribed by a doctor. These include:

• Opioids: Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems and blood pressure fluctuation. Taking these drugs for a longer time can lead to habitual use and physical dependence.
• Steroids: Inflammation-reducing drugs that can be used to treat various diseases systemically. It is called a systemic treatment if the medication spreads throughout the entire body. This happens when it is taken as a tablet, injected into a muscle or given through a drip (infusion).Systemic steroids can soothe inflammation and relieve pain. They can also increase the risk of certain medical problems, including stomach ulcers, osteoporosis, infections, skin problems, glaucoma and glucose metabolism disorders.
• Muscle relaxants: Sedatives that also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect the functioning of your liver and cause gastrointestinal (stomach and bowel) complications. Benzodiazepines such as tetrazepam may lead to dependency if they are taken for longer than two weeks.
• Anticonvulsants: These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
• Antidepressants: These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat and fatigue.

Anticonvulsants and antidepressants are typically not used unless the symptoms last for a longer period of time or the painkillers don't provide enough relief.

Manual therapy and treatments based on physical stimuli

The treatment options for sciatica following a slipped disc also include manual therapy and treatments based on physical stimuli. Manual treatment may include massages and special techniques for relaxing tense muscles or locked joints. Treatments based on physical stimuli use warming and cooling methods to relieve pain. These treatments are also called passive therapies because patients don't have to actively participate. Common treatments include:

• Massages: Various massage techniques are used to relax muscles and ease tension.
• Heating and cooling: This includes the use of hot packs and heating patches, a hot bath, going to the sauna or using an infrared lamp. Heat can also help relax tense muscles. Cold packs, like cold wraps or gel packs, are also used to help soothe irritated nerves.
• Ultrasound therapy: Here the lower back is treated with sound waves. The small vibrations that are produced generate heat and relax the body tissue.

There is no overall proof that passive treatments speed up recovery from a slipped disc or relieve the pain especially well. But many people find that heat or massages are pleasant and relaxing.

Traditional Asian medicine

Treatment approaches based on traditional Asian medicine include:

• Acupuncture: In ´´acupuncture the therapist inserts fine needles into certain points on the body. This is thought to relieve the pain..
• Reiki: Reiki is a Japanese treatment which aims to relieve pain by using specific hand placements.
• Moxibustion: This method is used to heat specific points on the body by placing heated needles or glowing sticks made of mugwort ("Moxa") close to those points.

There are very few good-quality studies on these treatments, and there is no proof that they help to relieve pain. Acupuncture is the only approach for which there is weak evidence that it might relieve pain – although this relief has been shown to be unrelated to where the needles are placed on the body.

Injections near the spine

Injection therapy mainly uses local anesthetics and/or inflammation-reducing medications like steroids. These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:

• In lumbar spinal nerve analgesia, the medication is injected directly at the point where the nerve root leaves the spinal canal. This has a numbing effect on the nerve root.
• In lumbar epidural analgesia, the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment the spine is monitored using computer tomography or x-rays to make sure that the injection is placed at exactly the right spot.

Injections close to the spine can have side effects such as bleeding, infection and nerve damage. A treatment involving injections over a longer period of time may also lead to muscle weakness and is associated with radiation exposure due to the use of x-rays. For this reason, only a limited number of injections may be given. It is important to carefully weigh the pros and cons of having multiple injections.

Studies on treatments with injections have shown that they are able to relieve sciatica for several weeks. People were able to move more easily while going about their day-to-day activities as a result. Steroid injections seem to be somewhat more effective than other types of injections.

Treating pain and staying active

Acute low back pain usually has no clear cause and goes away on its own after a few days. And even if a slipped disc is causing it, your body will probably be able to make the problem go away on its own within six weeks. Most treatments hardly affect the speed of recovery. Hot packs or massages might help you feel better. If you have severe pain, short-term relief can be provided by getting into a position that reduces the strain on your back and by using anti-inflammatory drugs or local anesthetics. But most of the work is usually done by the body itself.

If slipped disc symptoms persist for a longer time, surgery may be an option to try to relieve the pressure on the affected nerve. However, most experts believe that slipped disc surgery is done more often in Germany than is actually necessary. So it might make sense to get a second opinion if your doctor advises you to have surgery and you aren't sure whether this is the right treatment.

It is particularly important to stay as physically active as possible despite the pain. Exercise will not only keep your body in shape, it generally also has a positive effect on your mood. Getting enough exercise and keeping up the strength of your torso (core muscles) is key in order to stop back pain from becoming chronic. Physical activity has been scientifically proven to have a preventive effect – and it is probably the most important thing you can do to help yourself.

Under certain circumstances, slipped discs in the lumbar spine region can be treated with surgery. This usually involves removing spinal disc tissue to relieve the pressure on irritated nerves. Surgery can often provide long-term relief from symptoms, but is associated with certain risks.

Surgery is always performed if the slipped disc is an emergency: for example, if prolapsed disc tissue is affecting nerves so severely that the bladder or bowel no longer function properly, or certain muscles have become very weak. But this only happens rarely.

Far more commonly, surgery is performed because other treatments haven’t provided enough relief from severe pain despite being used for more than six weeks. The question of whether to go through with surgery is often difficult to answer, though. For surgery to be considered, imaging techniques and the symptoms must clearly show that a slipped disc is in fact responsible for the pain. Before deciding to go ahead with the procedure, it’s important to carefully weigh the pros and cons together with your doctor. Your individual circumstances will also play a role in the decision because they can influence the success of the treatment.

Surgical techniques

The aim of surgery is to remove spinal disc tissue that is pushing on the nerve. The idea is to give the nerve more space so the inflammation can go down and the symptoms can go away. Various surgical techniques can be used when operating on a slipped disc:

• Open discectomy (microdiscectomy): “Open” discectomy is the most commonly performed type of surgery for a slipped disc. The damaged part of the spinal disc is removed and the surgeon is able to see the area being operated on using a microscope. People who have this microsurgical procedure are given a general anesthetic and have to stay in hospital for a few days. The risks associated with this procedure include bleeding, nerve damage and infections. A general anesthetic may lead to complications like breathing or circulation problems.
• Endoscopic surgery: Endoscopic surgery – also called minimally invasive or keyhole surgery – uses very small instruments so only one small cut is needed. This is done to speed up recovery and prevent the formation of scars that may cause problems. In these procedures, an endoscope (a long, thin tube that has a light and camera at one end) is inserted through a small cut and pushed through to the spinal disc. The surgical instruments are all inserted through this cut under x-ray guidance. The risks associated with this procedure include bleeding, nerve damage and inflammation.
• Surgery on the nucleus (inner core) of the spinal disc: In these “indirect” procedures, the gel-like core of the spinal disc is removed to make the spinal disc smaller, which in turn reduces pressure on the pinched nerve. All of these procedures involve inserting an instrument into the spinal disc to reach the core. The core of the spinal disc can be removed using suction. This is called percutaneous nucleotomy. Another option is to vaporize the core using laser beams (laser discectomy). This can cause side effects, such as heat-related tissue damage. These operations can only be done if the outer layer of the spinal disc is still intact.

Surgery can help, but there is no guarantee that symptoms will disappear

The different surgical procedures described here have been looked at in a number of studies, and some have been compared with one another. Most of the studies involved surgery on people who had pain for weeks despite receiving other treatment. One of the larger studies mostly included people with severe sciatica (sciatic nerve pain). The outcome: If someone is a suitable candidate for surgery, it can relieve pain and other symptoms such as limited mobility over the long term. The pain in the participants who had surgery went away quickly after the procedure. But it took a few weeks before there was an improvement in mobility. There is no guarantee that surgery will relieve all of the symptoms.

Research has shown that rehabilitation immediately after slipped disc surgery (follow-up rehabilitation) can shorten the recovery time and improve mobility.

Other surgical procedures

Sometimes more extensive surgery is performed – especially if the vertebrae are also damaged by wear and tear and the spine is no longer stable.

In a procedure called spinal fusion, the surgeon joins the vertebrae above and below the slipped disc together with screws so that they remain firmly in place. The spinal disc is removed, and the resulting gap between the vertebrae is filled with bone or a titanium implant.

Another option is to put in an artificial spinal disc (implant) that can be used without having to fuse the vertebrae together. The aim of this procedure is to relieve the pain and also avoid the kind of restricted movement that people experience after spinal fusion surgery.

Both procedures can have considerable side effects. These procedures haven't been shown to have more advantages than disadvantages.

The goal of rehabilitation is to improve the symptoms and restrictions resulting from a slipped disc, and strengthen the muscles in the torso in order to improve the stability of the spine.

Rehabilitation may include patient education, stretching and relaxation exercises, strength training and other measures. It is an option for people who have been greatly affected by their back pain and are unable to work or perform other everyday activities. Follow-up rehabilitation may help after surgery too.

Pain and restricted movement caused by a slipped disc subside on their own within six weeks in about 90 out of 100 people with this problem. It is believed that, over time, the body gets rid of part of the prolapsed tissue or that it shifts position so that the nerves aren't irritated anymore.

A painful slipped disc can go on to develop in very different ways: The pain can start very suddenly, and then disappear again very quickly. Some people have permanent pain that lasts a long time, while others have it again and again.

If the symptoms last longer than six weeks, it is unlikely that they will go away on their own.