Lumbar Disc Herniation: Symptoms, Diagnosis, and Treatment - Rehabilitation

Could my symptoms be caused by a herniated lumbar disc compressing the nerve root?

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Hello Dr.
Yin, I may have experienced a lumbar disc herniation last year, and I have some questions regarding the treatment process.
I would appreciate your guidance:
In 2013, I suddenly experienced severe pain in my left lower back, which a clinic physician diagnosed as general lower back pain, and it took several months to improve.
The following year, I had a similar episode with severe pain in my right lower back, which also took time to resolve.
After that, I occasionally experienced unilateral lower back pain.
During this period, I practiced the "knee-to-chest" exercise taught by the clinic every night while lying in bed, and sometimes did "straight leg raises" and "single knee bends with trunk rotation."
In early May last year, after sleeping on a hard bed, I woke up with pain in my left lower back around the sacroiliac joint area.
By June, it hadn't fully healed, and after walking a long distance, the pain recurred.
I endured the pain to walk back home, but it was gone the next day.
After that, the pain point was no longer painful, but about two weeks later, I started to experience pain in the "left lateral hip" (gluteus maximus) and "left outer hip" (gluteus medius) when standing or walking, which would ease when sitting or squatting.
The treatment process was as follows:
1.
On June 30, 2020, I visited the first clinic, where no physical examination was performed.
I underwent 12 sessions of lumbar traction with no effect.
The only relief came from using a vibrating massage device to relax the muscles around the sacroiliac joint pain point.
While standing, the pain in the left outer hip would only last a few minutes without pain.
The lumbar traction was ineffective, and I paused for a few weeks.
During this time, the therapist taught me to perform "straight leg raises at 90 degrees" while lying flat at night, which I did every night.
2.
On August 15, 2020, I went to the second clinic, where a physical examination was conducted, and a lumbar disc herniation was suspected.
I continued with lumbar traction, and the physician instructed me to raise my leg backward while standing and to continue doing the "knee-to-chest" exercise at night.
I also did the straight leg raises taught by the first clinic (later I learned that this action could exacerbate a lumbar disc herniation during the acute phase).
Halfway through the traction treatment, the pain in the left hip improved, but on September 18, after rehabilitation, I began to feel slight numbness in my left calf.
The physician mentioned that if the lumbar traction showed improvement, it indicated the treatment direction was correct (the opposite would mean no improvement or worsening, indicating an incorrect treatment method).
On September 25, after standing for a long time at work, the pain became unbearable, but improved after resting.
I still went for lumbar traction that night, but the next day the pain intensified.
After several long walks, the pain in the left outer hip worsened, and I began to suspect sciatica when sitting on hard chairs.
Later, there was no significant improvement, and before reaching half my body weight in lumbar traction, I was referred to a hospital for an MRI.
On October 6, the report indicated mild lumbar degeneration and spondylolisthesis, with the intervertebral disc at L2-L3 protruding posteriorly to the right, which appeared severe, but there were no abnormalities in the right lower limb (Images 1: https://imgur.com/8n2mdG0, Image 2: https://imgur.com/Ot8fjgP, Image 3: https://imgur.com/Tu9Gg58); the intervertebral disc at L4-L5 protruded posteriorly to the left, which appeared mild (Images 1, 2, Cross-section Image 4: https://imgur.com/fzXDTm2), and the report stated that the two intervertebral foramina were minimally encroached by the herniated disc.
3.
On October 5, 2020, I visited the third clinic, where no physical examination was performed, and I continued with lumbar traction.
At this point, in addition to numbness in the left calf, I also began to experience pain.
On October 15, while lying in bed and raising my left leg straight, I could only raise it about 30 degrees, causing pain in the back of my left thigh.
The next afternoon, I experienced severe pain in the left outer hip, making it difficult to walk, entering an acute phase.
On October 18, my left big toe felt numb with an electric shock sensation, which likely indicated that the fourth lumbar nerve was being compressed by the herniated disc, corresponding to the numbness in my left big toe.
I performed lumbar traction almost every day, and after more than a month, I improved by late November.
By December, I was pain-free, but I was left with symptoms of numbness in the "anterior lateral left calf and left big toe." After that, whenever I lifted heavy objects or walked long distances, I would experience some pain in the sacroiliac joint area and the left outer hip, with increased numbness in the left calf, which expanded to the calf and knee area.
In mid-November last year, I visited the hospital, and the physician reviewed the MRI cross-sectional images from early October, concluding that the intervertebral discs at L4 and L5 were protruding laterally to the left side of the intervertebral foramen, compressing the fourth nerve root.
The MRI images taken in mid-December appeared similar to those from early October, but the report indicated that the intervertebral discs at L4 and L5 were protruding into the intervertebral foramen and laterally, severely encroaching on the fourth nerve root.
However, Image 5 (https://imgur.com/D0UfMLz) looked very similar to Image 4 taken in early October.
After intensive lumbar traction, my left calf became numb, raising concerns.
In December, I had reached half my body weight in lumbar traction, but the numbness persisted, and I paused for three weeks.
In mid-January this year, I resumed lumbar traction, but it made the numbness worse, and the previously pain-free left outer hip began to hurt again, leading to a pause until now.
I want to recover from this condition, and I have the following questions:
Q1.
Am I experiencing intervertebral disc protrusion into the intervertebral foramen, causing "foraminal stenosis"? Is it true that when standing, the lumbar intervertebral foramen becomes smaller, compressing the nerve root and causing pain in the left outer hip, while sitting or squatting allows the lumbar spine to flex forward, enlarging the intervertebral foramen and providing immediate relief? I have this question because I know that the presence of a herniated disc does not necessarily mean symptoms will occur; the pain in the gluteus medius and gluteus maximus when standing may have other causes.
Q2.
Most lumbar disc herniations occur posteriorly and anteriorly to the spinal cord.
The posterior longitudinal ligament is located at the back of the lumbar vertebrae; if the ligament is not ruptured by the herniation (i.e., bulging as referred to in other contexts, with the annulus fibrosus intact), lumbar traction may help retract the herniation.
However, my condition is a rare case of protrusion into the intervertebral foramen laterally, where there is no posterior longitudinal ligament.
Will lumbar traction be effective in this case?
Q3.
The McKenzie exercises performed in a prone position are useful for posterior disc herniations as they can help push the herniation back.
Are they effective for "protrusions into the intervertebral foramen"?
Q4.
During the acute phase, a neurosurgeon suspected "neuropathic pain in the thigh" and only performed electromyography on both legs.
The report indicated "bilateral thigh cutaneous nerves could not capture SNCS signals, suggesting bilateral thigh cutaneous nerve lesions." Is this abnormality in the cutaneous nerve caused by compression of the lumbar nerve roots? Would electrical therapy worsen the condition? Previously, wearing tight jeans compressed my left hip, leading to numbness below the left hip.
Q5.
From 2013 to 2020, I performed the knee-to-chest exercise every night while lying in bed and bent forward while seated.
If I already had a herniated disc, does this flexion of the lumbar spine exacerbate the herniation?
Q6.
During the acute phase, does performing knee-to-chest, straight leg raises, and single knee bends with trunk rotation exacerbate the herniation? I have heard both supportive and opposing views during my treatment.

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Yu Sicheng, 40~49 year old female. Ask Date: 2021/04/22