Lower back pain is common and may precipitate disc rupture or herniation. Lower back pain will affect upwards to 80% of the population during their lifetime. A smaller percentage of this group will develop disc herniation requiring treatment. Most people begin to undergo degenerative changes or arthritis as they age. In the United States, lower back pain is only secondary to upper respiratory problems resulting in absenteeism from work. Lower back pain is the most common factor for disability in men and women under 40 years of age. Repetitive injury to the lower back or a sudden traumatic event may precipitate the disc herniation. The mean age for disc herniation is the mid 30’s; it doesn’t frequently occur below 20 years of age nor over the early 60’s.
What Happens When a Disc Herniates?
The disc is important for the function of the spine. It is a “shock absorber” of the spine and assists in the mechanics of movement. The disc is located between the body of the vertebra. The disc material is contained by the vertebral bodies above and below. The sides of the disc are made up of tightly criss-crossing fibers. This design gives strength and flexibility to the disc. Inside the disc is a small “marble like” liquid entity called the nucleus pulposus.As we age, the degenerative process causes less fluid to pass into the disc and the outer annulus becomes weaker resulting in a bulging of the disc. This progression distorts the disc and may lead to tearing or disruption of the criss-crossing fibers. This is when the disc is susceptible to rupture or herniation.Contributing factors to disc herniation may include:
- Postural stress and strain – repetitive bending, lifting and twisting
- Lack of muscular strength – trying to compensate for weakness when performing activities may increase the stress on the disc
- Smoking – reduces blood flow to the area and dehydrates the disc
- Sudden trauma – in a motor vehicle crash the seat belt holds the restrained driver’s pelvis to the seat of the car and the lumbar spine stretches and twists
- Sudden injury from lifting and twisting – lifting an object in an awkward position and twisting when the weight isn’t balanced
Diagnosing Disc Herniation
Diagnosing disc herniation is not always as easy as it seems. There are many factors that can contribute to lower back and leg pain. Conditions such as, but not limited to, the piriformis syndrome, myofascial trigger points, lumbar stenosis, compression fractures, inflammatory conditions and other conditions affecting the bones of the spine can produce symptoms similar to a disc herniation.There are basic tests the doctor performs that may include the following:
- Tests that stretch the nerve
- Tests that produce a pressure on the nerve – such as coughing, sneezing or other orthopedic tests
- Checking for loss of sensation and strength in the legs
- Reflex check for decreased or absent knee or ankle jerk
- Palpation of the suspected level of involvement quantifying the amount of muscle spasm or swelling
- Observing the patient
Mechanical pressure can produce pain along the nerve, but a common inciter of pain is from the chemical debris and swelling from injury to the disc. This accumulates around the nerve root.
There is a confusion of terms used regarding disc injury. The following clears up the confusion.
- Disc Bulge – The disc weakens and over 30% of the disc bulges out along the remainder of the posterior part of the disc. The material in the disc remains contained within the disc.
- Disc Herniation – Generally less than 30% of the disc and the material inside the disc extrudes or escapes from inside the disc. The event has been called a “focal disc extrusion”. This injury can set up a chemical irritation of the nerve root or frank nerve compression.
- Sequestered Disc – The material in the disc breaks loose from its origin within the disc.
- Free Fragment – A piece of the disc material migrates up, down or along the nerve root. This can be troublesome for the doctor to make a diagnosis on clinical methods only. When it migrates away from the nerve root the symptoms reduce or completely go away, only to return when the fragment shifts back on the nerve root.
- Degenerative Disc Disease – This is a normal event of aging. The material inside the disc degenerates due to loss of hydration. Other material develops within the disc that causes loss of shock absorbing qualities and may alter the biomechanics of the back. This contributes to lower back pain. It has been stated that up to 8 out of 10 people over age 55 have x-ray evidence of degenerative disc disease. MRI findings of a bulging disc in asymptomatic individuals have been reported to be between 40-70% of people over age 40. History and examination findings help determine the correlation with the x-ray findings, MRI and patient complaints.
CT and MRI Scans for Disc Herniation
MRI is very helpful in arriving at the correct diagnosis of disc herniation and the level of the disc injury. CT scan may be 80% accurate in determining disc herniation. MRI scanning is the study of choice. The most common level of lumbar disc herniation is the disc at L4-L5. There is the danger of assuming a bulging disc is causing back pain. Research has determined over a 1-2 year period of time, the outcome of surgery compared to conservative management is about the same.
Conservative Management of Lumbar Disc Herniation
Research literature suggests conservative care be utilized for the initial treatment of a disc herniation. Chiropractic has had success in treating lumbar disc herniation. Treatment may include:
- Flexion-distraction – This creates a negative intradiscal pressure drawing the disc material away from the impinged nerve root. This may be done lying on your side when acute pain precludes lying on the stomach for treatment. Protocols are followed for maximum comfort and safety.
- High Velocity Low Amplitude Adjustment (HVLA) – This is also called diversified technique. Chiropractic care is administered with the patient side posture and rapid movement of the vertebra being carried out within its normal physiologic limits. The maneuver is brief and sudden. This produces rapid negative disc pressure at the instant of the maneuver.
- Physical Modalities – Ultrasound, electrical muscle stimulation, muscle relaxation techniques, ice and lower back brace or support may be used at the onset of care. Limiting activities of daily living to include work during the acute phase of treatment is also recommended. When improvement begins, structured stretching and strengthening exercise routines will be given with gradual discontinuation of the back brace. Reducing job restrictions and restoring more normal activities can be expected. When the sub acute stage has begun, more aggressive rehabilitation exercises including resistance, exercise ball and MedX equipment may be used. Low tech rehabilitation is less costly and is an effective protocol adding strength to the core and lower back. Swiss ball exercises are easy to follow and are good for the core.
- Co-Management – The doctors at Coon Rapids Chiropractic Office have found that in difficult cases co-management with a medical specialist may be helpful to resolve the disc problem and help prevent the need for surgery.
- Nutrition – Providing the proper nutrition to the body will assist in the repair of the injured disc. Refined sugar laden foods, high fat and salty foods, “fast food” and low fiber food should be avoided. An attempt to reduce caffeine, diet sodas and alcohol should be made. Foods that ease elimination are important as constipation can aggravate the disc injury from straining at the stool. Water consumption should be increased. Fruits, vegetables, fish, nuts, poultry and organically raised beef are good foods for the body to obtain nutrients. Oral supplements such as vitamins, minerals and herbs have been shown to help in disc repair. These include:
- Vitamin B (all)
- Vitamin C
- Vitamin D
- Vitamin K
- Calcium / Magnesium
- Willow Bark – has anti-inflammatory characteristics from Salicin, which has aspirin qualities
- Bromelain – found in pineapple and has an anti-inflammatory effect
Consult your doctor as nutricutical companies may have a special nutritional formula for disc repair.
Long Term Care
Treatment goals and recommendations after the acute episode has responded to conservative care are important to minimize reoccurrence. Research has indicated that at the 2 year mark when comparing conservative management such as chiropractic care to lower back surgery, the patients revealed no statistical difference in the treatment results. What actions can be done for management of a disc injury into the future? Here are some suggestions:
- Patient Compliance with Recommendations
- Weight Management
- Following Exercise Recommendations
- Job Modifications
- Recreational Modifications
- Good Nutrition
- Recognizing the warning signs that treatment may be needed and symptoms can no longer be controlled with self-care
- Being proactive by visiting the doctor for proper evaluation
Lumbar disc herniations may respond to conservative chiropractic care. Working with doctors that have an understanding of the non-surgical care and management of lumbar disc herniation is the first step in recovery. Co-management may be necessary in some cases. Not every disc problem responds to non-surgical care, and a referral for surgical consultation may be necessary.
The doctors at Coon Rapids Chiropractic Office have experience in the conservative non-surgical care and management of lumbar disc herniation.