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Herniated disc, prolapsed Disc, slipped disc..... And chiropractic Treatment
Causes
Symptoms
Assessment
Slipped disc, bulging disc, prolapsed disc..... these are all common terms used to define types of injury to the discs which sit between the vertebrae bodies (bones) of the spine.
Commonly described as the "cushions" or "shock absorbers" of the spine, these circular pads of cartilage are composed of tough, fibrous tissue on the outside (annulus fibrosis) and a watery, gelatinous material on the inside (nucleus pulposus). A similar arrangement to a jam doughnut.
The fibres of the outer annulus are deeply woven into the vertebrae above and below. They are arranged in a series of rings which run at oblique angles to one another. This maximises strength into flexion (forward bending) and extension (backwards bending). It also allows maximal resistance to torsional (twisting) forces.
The inner nucleus is hydrophilic (water loving). This means that when it's not under compressive force it draws in water causing the disc to swell in size. This happens every night while we sleep and is the main reason we are taller first thing in the morning.
An Intervertebral Disc
A key role of intervertebral discs is to dissipate loads during spinal movement. However, these structures can often become injured and can cause both local and referred pain.
What causes a disc to become injured?
As part of the natural aging process, alterations to the disc structure can occur. Firstly, the nucleus loses its' water content which can result in the annulus bulging outwards beyond the margins of the vertebral body, much the same as a flat tyre would do against the road surface. These age-related changes are very common in patients aged over twenty and are often not associated with symptoms. A "Disc Bulge" per se can be classified when 50-100% of the circumferential disc tissue extends beyond the normal boundaries(1).
Actual injuries can also occur to the internal nuclear and annular structures within the disc. This is referred to as a herniation and these derangements may occur either slowly or quickly secondary to either degeneration or as a result of accumulative microtrauma. The mechanism of injury is based primarily on compressive forces in repetitive flexion, often with superimposed torque or rotation(2).
Despite obvious trauma and faulty postures, other factors have now been demonstrated to be associated with the development of disc herniations in the low back including a family history (3) , sedentary occupations(4), obesity(5) , smoking(6) and ages between 30-40 years. This latter finding can be explained by the disc still being hydrated yet having had enough time to accumulate some repetitive strain.
Where do disc herniations occur in the lumbar (low back) spine?
About 90% of lumbar disc herniations occur at the two lowest discs which are positioned between the L4/L5 and L5/S1 vertebrae1 and 93% of these herniations protrude into the spinal canal. Unlike early theories regarding disc herniation, rarely does the injured disc itself cause direct compression to the exiting nerve root. Instead, it is now considered that an uncontained disc herniation is seen as foreign by our bodies and an immune response is mounted similar to an inflammatory response produced after exposure to a flu virus etc. It is these inflammatory agents which are toxic to the nerve root resulting in direct irritation, localised muscle guarding and "sciatica".
Symptoms
There can be a large variation in the severity of pain with lumbar disc injuries and resultant nerve irritation ranging from severe back, buttock and leg pain, pins and needles, muscle weakness in the legs and changes in urinary habits/bowel movements to no obvious symptoms at all.
This can be explained because it is only the outer 1 to 3 mm of the disc which is pain sensitive. Furthermore, it is the extent of the chemical (from inflammation) or mechanical (from direct pressure) pressure which determines the severity of the nerve symptoms. Such that, nerve roots are adapted to withstand a degree of mechanical or chemical irritation however, once this threshold is exceeded, symptoms will be felt by the patient.
The symptoms derived from irritation of the nerve root is defined as radicular pain. This pain is often described by the patient as one sided, constant dull "toothe-achey pain" which can occasionally be sharp and lancinating in character. It often follows a distinct pattern within the lower limb which is defined as a "dermatomal" distribution. There may also be changes in sensation such as numbness or pins and needles.
The symptoms described by patients often relate to aggravating positions which increase the pressure in the discal material namely sitting, standing, coughing, sneezing etc or with manoeuvres which increase the traction on the nerve roots i.e. straightening the leg etc.
Assessment & Diagnosis
As with any injury presenting to Bodymotion, taking a case history is often one of the key factors which may highlight the possibility of discal involvement.
Following the case history is an orthopaedic and neurological assessment. By testing sensation, muscle strength, and reflexes, our chiropractor at Bodymotion can often establish the location of the herniated disc.
An MRI scan is also an extremely beneficial tool to aid in the diagnosis of disc injury and provides information on the severity of the injury and degree of neurological compromise. The MRI scan takes two and three dimensional pictures of the spine using a large magnet and radio waves. The patient is most commonly placed on their back and slid into a small tube containing very strong rotating magnets for approximately 20-40 minutes.
It is important to note that MRI scans cannot be relied on solely and must be compared with clinical findings and symptoms before any intervention/ treatment can be considered.
This was clearly demonstrated in a study by Jenson & Modic et al. 1994(7) . These authors found that 52% of the 98 asymptomatic patients that were scanned using an MRI scan demonstrated a disc bulge and 27% demonstrated a disc protrusion. Only 1% of the patients had a full blown disc extrusion which demonstrates that MRI is quite accurate for detecting disc extrusions. Out of all 98 volunteers, 64% had an abnormal disc on MRI (bulge, protrusion, and/or extrusion).
At Bodymotion Chiropractic, we often refer patients for MRI scans at Vista diagnostics. Vista use an excellent modern scanner and the reports are written by highly regarded NHS radiographic consultants. They are conveniently located next to Waterloo Station, are open seven days a week and offer excellent value for money with prices for scans starting at £200.
Treatments
Given the age and occupation of our patient base, we regularly treat disc injuries. Every patient that presents at the Bodymotion Clinic receives approximately 1 hour assessment. This involves a thorough history to decipher possible mechanism of the injury and a full orthopaedic, neurological and chiropractic assessment. Every patient with low back pain receives a battery of tests to ascertain if there are any clinical signs of disc disruption and/or subsequent nerve irritation. Although rare, occasionally we have seen patients which are completely unaware of muscle weakness and reduced sensation in there lower limb but this can be highlighted through our thorough assessment procedure. This is normally adequate to diagnose the patient but occasionally they may be sent for further imaging (X-ray or MRI) where appropriate.
Once a diagnosis involving disc disruption is made, the possible treatment interventions are discussed and a treatment plan is then agreed with the patient. Typically, this will involve a combination of the following interventions:
Medication: Where appropriate painkillers such as paracetamol and anti-inflammatories may be advised.
POSTURAL ADVICE (SITTING, STANDING AND LAYING): This not only helps reduce symptoms but allows the healing process to begin.
Functional advice: Patients are encouraged to stay as active as possible. We therefore take time to advise patients how best to maintain a normal lifestyle as possible without aggravating the complaint. This may range from how to pick a newborn baby out of a cot to modifying gym/training programmes.
Cryotherapy: Cold packs are often advised for acute patients. This can help reduce pain and inflammation.
Muscle relaxation techniques: The low back muscles can often become very tense in an attempt to splint the low back. This can sometimes distort posture causing a lateral lean of the body. Our chiropractors are trained and experienced in deep tissue massage and trigger point therapy. They may also use very specific stretches to relax and lengthen short tight muscles.
Joint manipulation/mobilisation: Chiropractors receive very specific training on mobilising and manipulating restricted (stiff) joints. This may relieve pressure on the spinal segment with the disc derangement.
Nerve mobilisation: Nerves are dynamic structures and lengthen and shorten depending on our position and movement. Specific techniques are utilised to allow the nerve to move more freely in order to reduce irritation and ease symptoms.
Movement patterns: We may all perform similar movements but how we get there and which joints and muscles we bias can be very different. This is because of many reasons such as genetics, lifestyle demands e.g. desk based work, sporting/exercise history, learnt behaviours e.g. parents postures, etc. This is very important as disc injuries are rarely a result of a one off trauma but are more often an accumulation of trauma which goes unnoticed due to the lack of pain sensitive nerves in the disc itself. A good example would be somebody who tends to flex their low back more when bending forward rather than bending from their hips. This will typically cause the nucleus of the disc to be repetitively forced backwards. It's no coincidence that this is the most common area for disc herniations to occur. Once the patient is moving relatively painfree and moving in a more natural pattern the Bodymotion chiropractors will teach the patient to correct these patterns via a structured exercise programme. An individually tailored home exercise prescription is given to the patient with clear instructions and diagrams from our physiotools database.
Lumbar stabilisation exercises: Following an episode of low back pain it has been demonstrated that deep abdominal and back muscles can become dysfunctional (10). At the clinic we teach our patients individual specific exercises to recondition these muscles.
In the very unlikely event of the patient not responding to care or if the initial assessment findings warrant it, an MRI scan and possible surgical opinion may be sort.
Chiropractic has been shown to be very successful in the treatment of disc injuries. A study of patients with cervical and lumbar disc herniations receiving chiropractic treatment showed 80% improvement in terms of reduction in pain and resolution of abnormal examination findings and 63% of patients on follow up MRI investigation following chiropractic treatment showed a the disc herniation had reduced in size or completely resorbed (BenEliyahu, 1996).
Further treatment options
Surgical procedures: This is rarely required and with the exception of emergency cases is only considered when a patient has failed to respond to more conservative care measures i.e. rest, medication, physical therapy (chiropractic) etc.
The advent of MRI scans has allowed for the greater use of less invasive surgical interventions with keyhole surgery becoming more common. Dependent on the location and size of the herniation, either the whole disc (complete discectomy) or part of the disc which has herniated (partial discectomy) may be removed. If the disc is completely removed then the vertebrae body above and below will need to be secured which may be done by taking a bone graft from elsewhere (often the pelvis) and fusing the vertebrae together or alternatively, a metal spacer may be placed between the vertebrae with oblique screws being positioned into the adjacent segments. There is much research being conducted to produce an artificial disc replacement but given the complexity of the structure it is proving very difficult.
Epidural injections: Occasionally injections of corticosteroids and anaesthetics may be used to reduce inflammation and pain despite there being lack of well designed studies to support the use of this intervention with discogenic pain (8). However, some research papers have shown that such injections may be successful in reducing chronic low back pain when associated with sciatica (9)
If you are concerned about your back pain and would like some advice please do not hesitate to contact one of our chiropractors at the clinic
(1) Tarakad S Ramachandran, MBBS, FRCP(C), FACP (2008) Disk Herniation. Emedicine.
(2) LeFebvre, R et al. Herniated lumbar disc with radiculopathy (1999) Conservative Care Pathways 5-53.
(3) Battie & Videman (2004) Spine 29(23): 2679-90.
(4) Deyo R, Rainville J, et al. What can the history and physical examination tell us about low back pain? JAMA. 1992: 268:760-5
(5) Hellovarra M. Bodyheight, obesity and risk of herniated lumbar intervertebral disc. SPINE 1987:12: 469-72
(6) Lindal E, Stefansson SO. Connection between smoking and back pain, findings from an Incelandic general population study. Scand J Rehab Med. 1996: 28: 33-38
(7)Jensen MC, et al. "MRI imaging of the lumbar spine in people without back pain." N Engl J Med - 1994; 331:369-373
(8)dePalma MJ, Slipman CW. Evidence-Informed Management of chronic Low Back Pain With Epidural Steroid Injections. The Spine Journal - 2008 (8): 45-55.
(9) B.W. Koes, R. Scholten, J.M.A. Mens and L.M. Bouter, Epidural steroid injections for low back pain and sciatica: an updated systematic review of randomized clinical trials, Pain Digest 9 (1999), pp. 241-247
(10) P.W. Hodges and C.A. Richardson, Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis, Spine 21 (1996), pp. 2640-2650.
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