Herniated Disc, Prolapsed Disc, Slipped Disc and Chiropractic Treatment

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). 

With regards to the neck, these injuries are frequently encountered by office workers who spend prolonged periods looking down at documents, laptops or mobile phones. It is therefore actively encouraged to improve your workstation setup to reduce the amount of time spent with the neck bent downwards whether this be through the use of a document stand or separate laptop stand and keyboard.
 
 
Where do disc herniations occur in the cervical (neck) spine?
 
The majority of disc bulges within the cervical spine are between the lower two vertebrae within the cervical spine namely C5-6 and C6-7. At these sites, these discal injuries can cause local irritation or compression to the C5, C6, C7 or C8 nerve roots
 

Symptoms of a cervical disc herniation/bulge

There can be a large variation in the severity of pain with cervical disc injuries and resultant nerve irritation ranging from no obvious symptoms to severe persistent neck and shoulder pain to arm pain, pins and needles and muscle weakness in the arm and hand musculature.

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 upper 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, coughing, sneezing etc or with manoeuvres which increase the traction on the nerve roots i.e carrying shopping

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 a 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.
 
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 for a cervical disc herniation/bulge

 Given the age and occupation of our patient base, we regularly see 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 neck 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 their upper 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 neck and mid back muscles can often become very tense in an attempt to splint the cervical spine. This can sometimes distort posture causing a side bend of the neck. 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.  

Cervical traction: This can be very effective at alleviating local nerve compression/irritation and joint stiffness at the site of the discal injury  

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.  

Exercise prescription: Once the patient's symptoms have started to ease it is vitial that any faulty posture, muscular imbalances and weaknesses are addressed otherwise, the sympotms can recur. An individually tailored home exercise prescription is given to the patient with clear instructions and diagrams from our physiotools database.

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.  

   
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.