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Disc Herniation

What is a disc herniation ?

Disc herniations occur when there is an imbalance between the pressure being exerted by the disc in the middle and the wall containing the disc on the outside. When this imbalance occurs the disc material in the middle of the disc, also known as the “nucleus pulposus” can push through the outer wall, also known as the “annulus fibrosus” into the spinal canal. This can occur without actually causing any problem; however it can cause direct compression to the nerve root. Often disc herniations can cause a degree of back pain as well as leg pain or sometimes just simply leg pain. On occasion the disc herniation can simply manifest itself as back pain. Disc herniations have many names; they can be called a disc herniation, a disc protrusion, a prolapsed disc, a disc bulge, an extruded disc or a sequestered disc. By and large these are all the same. There are some minor subtleties associated with where the disc actually is and as to whether the disc actually detaches from the disc wall. When the wall is intact but weakened allowing it to deform, the bulge is often called a disc herniation. If the disc material breaks through the wall it can be called a disc protrusion. If the disc material pushes out beyond the wall and along the back of the vertebral body it is often called an extruded disc. This would be akin to toothpaste being pushed out of a toothpaste tube. Finally if the disc actually detaches and hides away from the actual disc wall it is often called a sequestered disc, which taken literally means that it is either removed or separated from the disc itself. In these situations the disc fragment can often be hidden remotely from the actual level of the disc itself. The commonest symptom that the patient actually feels from a disc herniation is leg pain, also known as sciatica. Where the patient feels the pain in the leg depends on which nerve root is being compressed. Sometimes disc herniations can cause buttock pain with minimal back or leg pain. The important nerves, which we have to be careful with, when they are compressed, are the sacral nerve roots.

Sometimes compression of the sacral nerve roots can be a medical emergency and causes what is known as “Cauda Equina” syndrome. This may start with pain or weakness in both legs. Also patients may have a feeling of pins and needles (paraesthesia) or numbness around their saddle area or worst-case scenario, frank loss of continence, with loss of control of bowel and/or bladder function. The saddle area is the area, which, if you sat on a saddle, would be the part of your skin, which would be in contact with it. This is also known as the perineal area or the perineum. I often refer to it as the 'nether regions'.

How I manage disc herniations.

When examining you my primary concern is whether you have any loss in neurological function. I don’t need to prove you have back or leg pain, because I believe you.

In order to diagnose a disc herniation you will need an MRI scan. I will send you for a scan either at The Priory Hospital or if you are claustrophobic to the Open Scanner at CMC Imaging in Knowle.

I also always perform an x-ray of your lumbar spine in a standing position as this can often highlight things that are missed on an MRI. This is because you have to lie down to have an MRI and if you spine moves forward from a lying position when standing it will be missed on the MRI.

At your review appointment I will go through your scan with you and show you your disc herniation if you have one.

If you do have a disc herniation, the options available are watch and wait, physiotherapy, acupuncture, an injection or an operation.

I don’t believe there is any place for manipulative therapies for disc herniation and the disc cannot be pushed back into place.

Before 6 weeks.

It is important to remember that 80% of disc herniations get better by themselves in 6 weeks. This occurs by the body recognizing the disc material as being in the wrong place and sending special cells to the area of the disc herniation to “eat” it up. This is known as disc resorption, in that the disc is resorbed. During this time it will be extremely painful and unfortunately there is no evidence that any form of therapy will speed up the rate at which the disc is resorbed.

During this time it is important to take anti-inflammatories regularly as well as codeine based preparations with Paracetamol. If the pain is very severe you may need morphine based medication.

During this time it is also very important to stop you back seizing up and this is where Physiotherapists, Chiropractors and Osteopaths can play a vital role to teach you the relevant exercises to keep your back mobile.

Having Acupuncture or using a TENS machine may help but it is important to remember that in 8 out if 10 cases the disc will be eaten away by the body’s natural defences in 6 weeks irrespective of what you do and anything you do is to control the symptoms.

Knowing this, I would not offer anyone surgery before 6 weeks as it is important to see if the problem heals naturally. The only exception to this rule is if you are developing progressive weakness (what we call evolving neurological compromise) in the leg or if you have cauda equina syndrome, which is a surgical emergency.

After 6 weeks.

Once 6 weeks have lapsed if you are still in pain then sadly you are in the wrong group (the 20%) and in these cases the disc can take anything up to 18 months to resolve.

In consultations I regularly say, “if you have a nut to crack it is better to start with a nutcracker rather than a sledge hammer”. What I mean by this is, surgery should always be the last resort. I often find that a great many disc herniations that have been present for more than 6 weeks can be treated with a spinal injection.

The rationale behind this is that we know that a disc herniation provokes an inflammatory response. The Roman scientist Celsus first described the cardinal signs of inflammation about 2000 years ago around 5 BC. These are:

  • Calor – heat
  • Tumor – swelling
  • Rubor – redness
  • Dolor – pain

In a disc herniation the nerve experiences all these symptoms and being compressed in a tight space, the last thing it needs is to be swollen.

All doctors tell their patients to take anti-inflammatory drugs. When taken orally they have to be absorbed by the stomach and get into the bloodstream to exert an effect. With an injection, anti-inflammatories are delivered directly to the area where the disc is.

It is important to realize that the anti-inflammatory drug does not speed up the rate at which the body’s natural defence eats away the disc. It just reduces the heat, the swelling, the redness and pain in the nerve. Once the nerve is less swollen it is no longer in contact with the disc so the compressive element is reduced and the pain associated with inflammatory process is also reduced. This is often referred to as the “Chemical Radiculitis” associated with a disc herniation. A radicle is the root from a germinating seed and in anatomy the radicule refers to the nerve root. An “itis” means that it is inflamed. So a “Chemical Radiculitis” is an inflamed nerve root secondary to the chemicals released as part of the inflammatory process. This is the fourth component of the inflammatory response described by Celsus.

Spinal injections

Spinal injections are performed as a day case procedure usually at The Priory Hospital under a light general anaesthetic. The procedure will be discussed with you once it has been agreed that an injection is required. Instructions for your admission will be received from the Reservations Team at the Priory Hospital. This will include your admission time and any instructions regarding being “nil by mouth”. Prior to the procedure it will be necessary to carry out some routine blood tests.

What to expect on the day of the injection

On the day of the injection you are allowed to have breakfast but cannot eat after 9am. You are however allowed water until 11.30am. Mr Ishaque usually operates on a Monday afternoon so you will be admitted onto the ward at about 12.00pm. On admission Mr Ishaque and Dr E J da Silva will see you in order to go through the consent and talk you through the procedure.

You will then be taken down to the anaesthetic room where you will greeted by the theatre team and all the necessary checks will be performed for your safety. At this stage Dr Da Silva will place a small cannula in the back of your hand to allow him to deliver the anaesthetic agents during the procedure.

You will then be walked into the theatre itself and shown how to climb onto the operating table in order to get comfortable.

Mr Ishaque will then mark your back with a marker pen using the x-ray machine to guide him regarding the entry point for the spinal injections. Mr Ishaque will then clean your back using standard surgical iodine and the procedure is carried out using a sterile technique.

You may feel a slight sharp sensation like a pinch which last a few seconds before Dr Da Silva administers the intravenous general anaesthetic which is the local anaesthetic being placed at the needle entry point but often you will already be asleep at this point. You will not feel the actual spinal injection which is much more comfortable and safer for yourself and Mr Ishaque, as he can be sure you will not move at a crucial point during the injection.

Please be aware that if you are needle-phobic (very scared of needles) then Dr Da Silva can make sure that you will not even feel this initial injection just under the skin.

Mr Ishaque routinely performs an epidurogram using either Omnipaque or Niopam in order to confirm correct placement of the spinal needle after using x-ray guidance in two planes, taking x-rays from both side to side and from front to back.

Once you have had your injection you will be helped back onto your bed and transferred to the recovery suite. As you have has an epidural injection it is standard practice to monitor your blood pressure for about half an hour before being sent back to the ward.

Once back on the ward you will be able to eat and drink in order to get your blood sugar levels up and you will be asked to rest for 90 minutes to allow the sensation to return to your legs and the effects of the general anaesthetic to wear off.

Usually you will be discharged by about 7pm and you will need to be picked up, as you will not be fit to drive on the day of the injection.

What to expect after the injection

Following your injection a follow up consultation will be arranged for you, this will be arranged for you 4 weeks following your procedure.

Immediately after the injection it is not unusual to have a slight increase in back pain but often the leg pain is immediately relieved. I would advise you take a few days off after the injection to rest and during this time it is important to keep taking your anti-inflammatory (Diclofenac, Ibuprofen or Naproxen) medication as well as any painkillers. It is fine to drive the following day but I would limit journeys to less than 40 minutes.  I have had a number of patients who have flown short haul within 1 week of the injection which although is not recommended, is possible provided you keep well hydrated, keep mobile during the flight and keep wearing your compression stockings to reduce the chances of a deep venous thrombosis (DVT) and more importantly a Pulmonary Embolism (PE). In the weeks immediately following the injection I would advise you to walk regularly as your symptoms allow and to avoid any strenuous exercise and in particular excessive bending, lifting or twisting. Swimming is an ideal exercise as you are supported and if you can’t swim then walking widths in the pool at progressively increasing depth provides increasing resistance helping to build strength and stamina.

In the majority of cases any discomfort associated with the injection should have passed within 2 weeks and the effects of the steroid should be becoming more apparent. I usually advise patients to wait 4 weeks before starting physiotherapy, which will also help with the longer-term recovery.

When to operate?

Being a surgeon, like all surgeons, I enjoy operating, however it is much more important skill to know when not to operate.
It is the “decision rather than the incision” that is most important.
Obviously there are times when an operation cannot be avoided and this is referred to in medical terms as an absolute indication. The only real absolute indication for disc surgery is when a patient has “cauda equina syndrome”.

There is however a graduation of symptoms which make the need for surgery more pressing. We refer to these as relative indications. These include loss of neurological function or progressing loss of neurological function. By this I mean worsening motor function or weakness with associated pain. If a disc herniation compresses one of the lower lumbar nerves enough to give a patient weakness, the weakness will usually manifest itself as a foot-drop. The evidence however for operating on a disc herniation for weakness or loss of power without pain is poor. By this I mean there is often no benefit from surgery for a “painless foot-drop”.

I will be able to guide you towards a decision about surgery but I feel very strongly that surgery should be the last resort unless absolutely necessary.

I also believe that in the majority of cases the final decision about surgery has to be made by yourself with the best possible information to hand to help you make the right decision.

Setting new standards in spinal treatment

Professional Memberships

Mr Ishaque is highly experienced and widely recognised as a leading Consultant Spinal Surgeon. He is one of the few surgeons to have been awarded both the British Orthopaedic Association's Robert Jones Gold Medal and a Hunterian Professorship from The Royal College of Surgeons of England. He is one of the youngest surgeons to have achieved this, having been awarded both honours, before the age of 40.

British Orthopaedic Association B A S S BMA Logo;Royal College of Surgeons