Lumbar Disc Injury Herniated Disc Bulging Disc Low Back Pain Sciatica

Dr. Wayne Coghlan: Chiropractor
Lumbar Disc Injury
Herniated Disc
Bulging Disc
Low Back Pain
Sciatica

There are several types of injuries and conditions that can cause "Low Back Pain." In this post, I will discuss lumbar disc injuries.

What is a lumbar disc? 

Lumbar disc and vertebra

A lumbar disc is located between each vertebral bone. They are somewhat comparable to a jelly donut with an outer layer of dense fibrous gristle like tissue, and an inner core of soft gel like tissue. They help hold the vertebrae together and allow for flexibility in the spine. 

When we are young, the disc is very flexible, strong and resilient.... consider a brand new rubber band or washer from a household faucet...and it takes a lot to injure it. 

Degenerated and Bulging Disc

As we age the disc material become stiffer, less hydrated, less resistant to wear and injury.... just as the old rubber band or washer becomes dry and brittle. The disc gradually becomes thinner and pushes out at the sides causing strain and pain to ligaments. The fibrous outer ring becomes less resilient and accumulates fissures. If the disc is subject ot s hard enough sudden overload - as when reaching out and lifting, or the disc has just deteriorated so much that is cannot resist a low grade force - as when you sneeze, the soft gel like material inside the disc can push out. Squeeze a jelly donut for an example.



Lumbar disc injuries range from strained ligaments around the disc - similar to a sprained knuckle, to a bulging disc, to complete rupture and herniation. The pain, complications, and disability are usually proportional to the degree of injury, especially if a bulging or herniated disc is pressing on a nerve. And yet, at times, a disc can herniate with minimal pain or disability. It is usually the tissues around the disc that cause the most pain. Similarly, there can be much pain with even a relatively minor disc injury.

Load on disc varies with posture.

A disc injury does not exist on its own. It is usually the result of progressive wear and degeneration due to repeated low-grade stress and micro injury.  The image on the left identifies the load on the disc with various postures, taking standing with good posture as a baseline. One can see how common habits such as slumping and careless lifting cause tremendous loads in the disc. 

Sway Back

There are usually concurrent problems with the muscles, ligaments and vertebral (spinal) alignment and mechanics. The image on the right demonstrates a common posture with weak and slack stomach and core muscles, and the resultant increased curve and load on the lower back. 

A lumbar disc injury, as with a broken ankle or sprained knee, needs to be respected lest it becomes a chronic if not a permanent disability. The problem is because we can't actually see the swollen tissue and many people just try to tough their way through the injury ... or fail to recognize what they are doing to aggravate it.... and make it worse.

Diagnosis.

It is wise to see a health care professional to evaluate your injury and ensure that any red-flags - indications of a more serious illness or injury - have been recognized and dealt with. A reasonably fit person with a sudden onset of pain while or shortly after reaching out and lifting something heavy is a fairly typical of a herniated disc. A potentially worrisome example is a middle-aged or senior person with pain that develops without a defining injury event. It is your option to first see a medical doctor, however, chiropractors are well educated in diagnosis your injury and recognizing the cues that a person's back pain may be from a more worrisome cause and will refer you for further investigation as appropriate.

Generally, a herniated injury can be diagnosed clinically - that is in how the injury developed and how it is affecting the patient. With a lower grade injury, conservative management and monitoring for improvement is appropriate. X-rays may be useful to evaluate the overall health of the lumbar spine. A CT scan or MRI can be more definitive in diagnosing a herniated disc and ruling out pathology, however, advanced imaging does not necessarily change how a moderate disc injury ought to be treated. 

The problem with doing unnecessary testing is the increased cost passed onto the health care system for MRIs and CTs that really do nothing more than reassuring the patient they have a normal disc injury. The clinician has to balance the value of ordering the tests against risk of not doing the test. Eg: Is it more of a risk to the patient to subject them to radiation than avoid the radiation and monitor them for progress?

Sciatica

A typical indication that a disc is pressing on a nerve is pain radiating down one or the other leg... commonly referred to as sciatica. The more severe the disc bulge or herniation pressing on the nerve, typically the further down the leg and the more severe and longer lasting the leg pain. However, sciatica like pain can be caused by other problems such as radiation from other damaged tissues and compression of the nerve by muscles. 

If there is impairment of nerve function indicated by disabling numbness and weakness in the leg or foot... such as an inability to walk on one's heel... I would refer for a surgical consultation. However, the surgeon may wish to monitor the condition for a few months ...yes months... before committing to surgery. 

Note: If there is pain and/or numbness in the saddle region, and/or loss of the ability to control one's bladder or bowel function - can't go or can't stop from going - this is considered a medical emergency and can become permanent... surgery may be necessary - go to the hospital now!

Treatment: 

Up to about 20 years ago, it was commonly recommended that one should take pain relievers and rest in bed until the pain had resolved. The problem with this approach causes the person to become weak, fearful of pain, and prolongs recovery....perhaps even encourages permanent disability.

Disc surgery was also much more aggressively pursued...and for many, it seemed to provide relief in the short term. People reported having less pain after the procedure, but it is less clear that they felt better from the effects of the surgery or the several weeks of bed rest and medication. However, with long term follow up, it was determined that people who had disc surgery were no better off, and sometimes worse, than people who did not have surgery and learned to manage their condition conservatively.... that is ... progressive mobilization, correct faulty habits and improve core strength.

Where there is loss of reflexes and progressive muscle weakness, surgical evaluation is appropriate. Advanced imaging is used to evaluate if the patient is a candidate for surgical intervention, that is, can they identify a problem that is consistent with the pain pattern and can reasonably be corrected by the procedure?

Regardless of conservative management or surgical intervention, correcting one's back care habits is essential to long term improvement and stability.

This is where medical treatment can fall short unless it will deal with the concurrent issues. 

In my experience, most physicians will not make the time nor have the inherent understanding of the injury to promote care beyond symptom management. Medication is helpful to relieve pain...and good thing too!  But it does not correct the underlying contributing problems. Typically the pain will subside.... but the weakness continues and unless corrected.... more pain more often.  

Chiropractic  - at least my way - is a beneficial method of spinal care as I work to relieve pain... and then treat the patient in totality ... the holistic approach is best.


An indication that such a disk injury is recovering is the pain gradually easing from the leg and becoming more central to the lower back.

If the pain is central to the lower back with minimal radiation down the legs, and the person is improving week by week.... conservative management is appropriate.


For non-complicated disc injuries...

1. If you allow yourself to be injured, you allow yourself time to heal. I am not talking about bed rest for weeks on end... and that would actually lengthen recovery.... But somewhere between babying and abusing one's self is a golden path.
2. Accept that it is going to be sore. The pain won't kill you....though you might think it might. Time is your ally.
3. Initially, it may take all the strength of character a person has just to get to the toilet.
4. Rest as is necessary. - When you are tired of resting do some gentle activity. 
5. When you are tired of being active, rest again. 
6. As the pain diminishes over the next few days to week, gradually increase activity.
7. Applying ice is best when the injury is fresh and pain is more intense. Use off-the-shelf medications as necessary. If necessary, your physician can prescribe stronger medications... but be careful... they each have their own side effects. If you think it's bad having a sore back... add constipation to the mix. 
8. Stretching such as knees to chest, pelvic tilts, camel/cat stretches are helpful. Gradually progress toward strength exercises such as planks. Sometimes laying on your stomach and raising your upper body by resting on your elbows will reduce the pain... if so.. do more of it... if it aggravates your condition... then don't do it.
9. You may find that when you move the wrong way, you will feel a twinge, tense your back and then your back will spasm. In that half second you can learn to relax instead of tensing up... this will help reduce the painful spasm. As best you can, relax through the pain, instead of tensing up. It helps. I've been there.
10. You will also find, as you become more able, that some activities such as bending forward without bending your knees first, or sitting in soft slumpy chairs will make your back worse. Learn that the things you do to protect your back when it is sore, are the same things that will protect your back when it is not sore. This is good to practice indefinitely lest the same things you have been doing to get injured in the first place, will continue to injure you in the future... until you do learn and practice this lesson.
11. Returning to regular activities too soon or for too long too soon can aggravate a new injury. You know you can stand on a new cement side-walk the next day... but if you drive a car on it, it will crumble. Why? Because it hasn't cured yet. You'll be glad you were a patient...patient!
12. You cannot cure a disk injury. You can, however, manage it. The degree you can manage a disk injury varies with each individual and what you are willing to do to help or further hurt yourself. Most of us get by very well with only minimal pain and occasional flare ups... but if you neglect some basic back care habits... it will be very sore again. See item 14 below.
13. Learn proper back hygiene and body mechanics. Work on good posture and core strength. 
14. Traction therapy is not indicated for new injuries. It may help for longer term management. Inversion tables (hanging upside down) is just as effective if you can tolerate the sensation of pressure in the head. If you wish to consider your options.. talk to me. See item 14 above.
15. A relatively minor back injury may take a few days to a week before the person feels confident in their daily activity. Moderate injuries may take several weeks to months before cautious resumption of daily life. Severe disc injuries may take at least a year before it seems stable. In general, the pain of a severe back injury has a half life of about 6 weeks. See item 14 above.
16. There is a tendency for an injured disc to progressively deteriorate until it stabilizes. Then it just continues to get older and more worn down. Working with your chiropractor can help slow the deterioration process and promote long term stability. See item 14 above.
17. Whatever you are doing, if you are becoming aware of aching in your back, it means you are stressing it. Change what and how you are doing it or risk re-injury. See item 14 above.
18. Chiropractic therapy is directed toward correcting and improving the movement of the joints. It is a good thing to help through the initial recovery and long term improvement.

While a disc injury is very painful, yes ....  it is very rarely dangerous to one's life. There is one exception - Cauda Equina Syndrome - This is when the disc presses on the nerves in the spine that control the bowel or bladder.... if there is a loss of sensation in the saddle region, or loss of ability to control one's bowel or bladder ... either you can't go or can't stop from going ... GET YOURSELF GONE TO THE EMERGENCY ROOM AT THE HOSPITAL for surgical evaluation, lest the condition become permanent and potentially fatal due to complications.