Lumbar Disc Herniation
What is a Lumbar Disc Herniation?
Disc herniation refers to a disruption of the fibers surrounding the disc and subsequent displacement of the nuclear material that lies inside the disc. This may result in radiating symptoms from inflammatory/chemical irritation or true mechanical compression of the nerve roots that sit next to the disc. Ensuing symptoms include pain, tingling, numbness or weakness in the distribution of the affected nerve root(s). Chiropractic Solutions can be an effective approach in managing these symptoms and providing relief.
Multiple factors contribute to the development of lumbar disc lesions. Repetitive mechanical stressors like compressive loading, shear stress, and vibration weaken annular fibers, eventually leading to disruption. Only the outermost annular fibers are innervated with nerves, so early disruption to the inner layers of the fibers may be asymptomatic.
Annular disruption is accompanied by an inflammatory reaction capable of producing a "chemical radiculopathy". Significant annular disruption can lead to disc bulging or herniation resulting in mechanical compression of adjacent nerve roots. Most radicular pain is thought to arise from a combination of mechanical and chemical factors. Mechanical risk factors related to the development of lumbar disc herniation include: sedentary lifestyle or occupation, driving motorized vehicles, vibration, smoking, previous full-term pregnancy, increased BMI, increased angle of the sacrum, and a tall stature.
Genetic factors and aging also play a role in lumbar disc herniation. Aging is accompanied by degradation of the discs molecular structure, rendering it more vulnerable to mechanical injury. In opposition, degradation causes dehydration, meaning less nuclear material is available to herniate. Symptomatic disc herniation has a peak incidence in the fourth or fifth decades. The condition is uncommon in children. Approximately 35-45% of adults will experience lumbar disc herniation at some point in their lifetime and the condition is more common in men.
The most accepted nomenclature for disc lesions is the use of the term "protrusion" to describe bulging of an intact annulus, "extrusion" to describe contiguous nuclear material that has herniated through the annulus, and "sequestration" to describe a detached nuclear fragment. The degree to which the periphery of the disc is involved may further classify lesions as "focal," meaning less than 25% of the disc circumference is displaced, "broad-based", involving 25-50% of the perimeter, and "circumferential" involving 50-100%.
What Will Disc Herniation Look and Feel Like?
The clinical presentation is dependent upon the degree of neurologic involvement. Asymptomatic disc herniations are present in 20-36% of the adult population. Lesions without mechanical compression may produce a chemical radiculopathy consisting of only local discomfort and pain, or sensory disturbances that radiate into the buttock or lower extremity, sometimes below the knee. Testicular pain is a possible consequence of lumbar disc herniation.
The following factors have a predictive accuracy of 92.3% for chemical radiculopathy in lumbar disc herniation patients:
Back pain < 5/10
Symptoms worse the next day after injury
Lumbar flexion range between 0 and 30°
Positive clinical inflammation score (at least 3 of the following: constant symptoms, morning pain/stiffness lasting over one hour, short walking not easing symptoms, significant night symptoms)
Mechanical compression of a nerve root can produce all of the earlier-mentioned sensory disturbances plus motor (strength) deficit and diminished reflexes. Radicular pain is described as sharp and superficial, sometimes accompanied by tingling and numbness. One should be alert for the presence of cauda equina symptoms (saddle numbness/ paresthesia, loss of bowel/bladder function, bilateral weakness, impotence, etc.). Cauda equina syndrome is present in approximately one in one thousand low back pain patients who present to primary care offices. Cauda equina patients who progress to urinary retention and incontinence will often have long-term urinary sphincter impairment, even after surgery and need to seek medical attention immediately.
Research by Nachemson has shown that intradiscal pressures vary based upon body position (sitting produces the highest posture followed by standing which is followed by lying side posture and finally lying supine produces the least). Holding weighted objects or flexing forward increases intradiscal pressure and often subsequent pain and should be avoiding in the early phase of injury. It follows that most disc lesions fit into the directional preference category of “extension biased”, meaning that they are alleviated by extension positions including standing, walking or lying on your stomach, but are aggravated by flexed positions like sitting, driving or bending. “Flexion biased” disc problems are alleviated by sitting, bending or squatting and are provoked by extension. One should discontinue any movement or activity that causes any sign of peripheralization - the phenomenon when pain emanating from the spine, although not necessarily felt in it, spreads further down the limb. Some degree of sensation loss is present in up to 80% of patients suffering from lumbar disc-related radicular symptoms.
Evidence of progressive neurologic deficit warrants surgical consultation, specifically if there are motor/strength deficits that persist after regular and consistent treatment, including physical therapy services.
How Do We Treat Disc Herniation?
Disc herniation with radiculopathy may be successfully managed via conservative treatment. In fact, the majority of disc herniations will reduce over time with non-surgical care. One very large study reported that 97% of all symptomatic herniations will not require surgery. The size of the herniation has no predictive value with regard to the failure of conservative management or likelihood of requiring surgery. Large “herniations” trigger a significant inflammatory response and generally regress more quickly when compared to contained “bulges” that do not benefit from reabsorption. Associated motor deficits improve over time for both surgical and conservatively treated patients.
The goal of conservative management should be to centralize symptoms (move symptoms back towards the source of pain in the low back), reduce pain & inflammation, decrease mechanical compression with improved body mechanics and improve functional core stability. Directional preference (extension versus flexion) is an important point of differentiation when selecting treatment plans.
Distraction manipulation (done here at Boulder Sports Chiropractic) decreases intradiscal pressure and has been shown to effective for lumbar disc herniation. We use a specific table here at BSC used to create more space around the nerve to reduce compression at that level. Using distraction will help to improve symptoms in order to prepare for a more active recovery in physical therapy. A study of 1271 low back pain patients determined that patients with related leg pain are considered to have a worse prognosis than patients with localized low back pain alone. Generally, the farther down the leg someone is having symptoms, the more severe the injury is and the harder it will be to treat successfully with conservative measures.
Judicious application of sciatic nerve flossing may help mobilize and desensitize irritated nerves, however caution should be used with acutely irritated nerve roots as nerve flossing may increase a chemical inflammatory response and therefore more pain. With that said, the technique is very effective for sub-acute and chronic nerve root irritation. Spinal mobilization with movement may help disc-related radiating pain. Myofascial release techniques would be performed on muscles of the lumbar spine and hip including the quadratus lumborum, lumbar erectors, psoas, piriformis, gluteus and tensor fascia latae (TFL) muscle. Therapeutic stretching should be performed to areas of tightness in the spine, hips, and thighs. Ice and laser modalities may alleviate some of the symptoms associated with lumbar disc herniation.
In addition to above treatments, physical therapy should be implemented to introduce a home rehabilitation program. This would include exercises to address spinal mobility, core stabilization (including abdominals, gluteal muscles and large muscles of the legs) as well as sciatic nerve mobility. Lumbar disc herniations have been shown to trigger fatty infiltration and weakness of the superficial and deep spinal stabilizers. Exercises should be prescribed for any identified functional weakness as strength around the disc will be the most effective long term treatment option. With that said, the most effective preventative measure for low back pain is strengthening. Being that recurrent low back has such a high incident rate after initial injury, it is worth it to proactively be strengthening related muscle groups including abdominals, gluteal muscles and leg muscles in order to reduce the risk for onset of low back pain.
A systematic review showed no significant long-term effect for surgery compared to physical activity-based interventions for leg and back pain from lumbar disc herniation. Disc patients undergoing lumbar discectomy have up to three times increased likelihood of requiring later surgical fusion. Disc patients with “severe” leg pain are responsible for over 80% of all disc surgeries, yet demonstrate the lowest reported global change and the smallest proportion of patients with a successful surgical outcome at two years. Neurosurgical consult is warranted for suspected cauda equina syndrome (changes in saddle function or sensation), progressive or profound weakness, and severe intractable pain refractory to 4-6 weeks of conservative care.
Our doctors are very successful at treating low back pain. If you have been suffering from low back pain or more specifically, disc herniation, click here to make an appointment to see how our doctors can help you.