Herniated Disc – Symptoms, Causes, Prevention and Treatments
Lower back pain can be a debilitating and concerning condition, and from our experience, there can be a lot of misinformation out there on the web that can scare us into what is really going on in our lower backs. A disc herniation can sound scary when read on scans and feel pretty horrible, but not all is doom and gloom. The most common areas we would see a herniated disc is of the lumbar spine, however is can occur in the cervical spine and very rarely in the thoracic.
What is the Lumbar spine?
Sometimes the best way to start is with a quick anatomy crash course. It is most common to experience a disc injury in the lower back. This is called the Lumbar spine. The spine is a very strong and robust structure, and even when it feels painful and vulnerable, it is never going to suddenly fall apart.
It is composed of five lumbar vertebrae, numbered L1-L5 and sits just on top of your sacrum/pelvis. In between the vertebrae is your intervertebral discs. Intervertebral discs are soft (but thick), gel-like cushions. They act as shock absorbers, allowing for movement, flexibility, and support in the spine.
Each intervertebral disc is composed of two main parts:
- Annulus Fibrosus: This is the thick, tough, outer layer of the disc. It is made up of strong, fibrous tissue. The annulus fibrosus provides structural integrity to the disc and helps contain the inner nucleus pulposus.
- Nucleus Pulposus: This is the inner part of the disc material. It is a gel-like substance that is primarily made up of water, collagen, and a type of protein called proteoglycans. The nucleus pulposus is responsible for providing the disc with its compressible, elastic and shock absorbing properties.
Together, these components work to absorb and distribute the forces applied to the spine during activities like walking, running, bending, and lifting. They also contribute to the flexibility and range of motion of the spine.
Between each vertebrae lie the lumbar nerve roots. The nerve root is an extension of the spinal cord. These spinal nerves run from the spinal canal, out through the lumbar spine and continuously branch out supplying sensation and muscle control to the hips and legs.
In addition to these, there are many ligaments, as well as big strong muscles that keep everything held firmly together.
What are the types of lumbar disc injuries?
There are several types of lumbar disc injuries or conditions that can affect the intervertebral discs in the lower back. Often you may see one of these on an MRI or diagnosed by your doctor. They are usually classified on a continuum of “severity”. More importantly, a lot of these can be natural processes of ageing and do not necessarily indicate a new injury.
Disc Tear (Annular Tear):
This occurs when there is a tear or fissure in the outer layer (annulus fibrosus) of the disc. It can happen due to trauma, repetitive stress, or as part of the degenerative process. An annular tear may be a cause of lower back pain and may contribute to other disc-related issues.
A disc bulge occurs when the outer layer of the disc weakens or deteriorates, causing the inner portion to push outward. This creates a bulge that can potentially put pressure on nearby nerves.
In a disc protrusion, a portion of the disc material (usually the nucleus pulposus) pushes outwards but remains within the confines of the annulus fibrosus. This means it doesn’t rupture or break through the outer layer of the disc.
Lumbar disc herniations occur when the inner material (nucleus pulposus) of the disc ruptures through a tear in the outer layer (annulus fibrosus). You may often hear this referred to as a slipped disc. Discs don’t slip and should be abandoned as a diagnosis.
A herniated disc can be very painful. This is normal, the body is trying to heal the area and we get a big influx inflammatory markers to the area. This big histamine response to the area to try and heal the body can persist for some time and is unfortunately a natural healing/bodily process.
A Lumbar herniated disc can be broken down into:
- Disc Extrusion: In this condition, the inner material (nucleus pulposus) breaks through the outer layer (annulus fibrosus) but remains connected to the disc. It is similar to a herniation but more severe.
- Disc Sequestration: This is a severe form of a disc herniation where a fragment of the nucleus pulposus breaks off from the main disc and floats freely within the spinal canal.
Disc Degeneration (Degenerative disc disease)
This is a natural ageing process where the intervertebral discs gradually lose their water content, become thinner, and lose some of their shock-absorbing abilities. This does not predispose you to having back pain or a bulging/herniated disc.
If there is one take home message from these lumbar disc injuries is that prognosis for recovery is really good! In fact, what we know to be true from research is, the worse your disc injury, the better your prognosis for recovery. That’s right, those who have a significant lumbar disc injury, have very good chances of symptom resolution and in many cases avoid surgery.
What are the symptoms of a disc bulge?
A disc bulge can cause a range of symptoms, and the severity and type of symptoms can vary depending on the location of the bulging disc and whether it’s pressing on nearby nerves or other structures. Common symptoms of a disc bulge in the spine may include:
- Localized Back Pain: Many people with disc bulges experience localised pain in the area of the bulging disc. This pain is often described as dull or achy and may be persistent.
- Radiating Pain: If the bulging disc presses on nearby nerves, it can cause radiating pain that travels along the path of the affected nerve. For example, if it is a lumbar disc bulge, it can lead to leg pain, and irritation of the sciatic nerve.
- Numbness and Tingling: Nerve root compression/irritation by a bulging disc can result in numbness and tingling sensations in the areas supplied by those nerve roots.
- Muscle Weakness: In some cases, a bulging disc can lead to muscle weakness in the affected limb. Weakness may be subtle or more pronounced, depending on the degree of nerve compression.
- Changes in Reflexes: Compression of nerves can also affect reflexes. Diminished or absent reflexes in specific areas may be a sign of nerve compression.
- Pain with Movement: Certain movements or positions, such as bending forward or twisting, may exacerbate the pain associated with a disc bulge.
- Bowel or Bladder Changes (in rare cases): Severe compression of the spinal cord in the lumbar region can lead to problems with bowel or bladder function. This medical emergency is referred to as cauda equina syndrome and requires immediate attention.
What are the symptoms of a lumbar disc herniation?
A lumbar disc herniation can lead to a variety of symptoms. The specific symptoms can vary depending on the location and severity of the herniated disc, as well as whether it is pressing on nearby nerves or other structures. Common symptoms of a lumbar disc herniation may include:
- Lower Back Pain: We can often experience a large degree of lower back, sacral or buttock pain.
- Sciatica: This is a common symptom of a lumbar disc herniation. It is usually described as leg pain that radiates from the back, following the path of the sciatic nerve. The pain can be sharp, shooting, or burning, and it may be accompanied by numbness or tingling.
- Numbness and Tingling: Compression of nerves by the herniated disc can lead to numbness and tingling sensations in the areas served by those nerves. This can affect the legs, buttocks, or other parts of the lower body.
- Muscle Weakness: Severe nerve compression can lead to muscle weakness in the affected limb. This weakness may be noticeable and can affect activities like walking or lifting.
- Changes in Reflexes: Reflexes may be affected by the compression of nerves. Diminished or absent reflexes in specific areas may be observed.
- Pain with Movement: Certain movements or positions, such as bending forward, sitting, or coughing, can exacerbate the pain associated with a lumbar disc herniation.
- Difficulty Standing or Walking: Some individuals with a severe lumbar disc herniation may find it challenging to stand or walk for extended periods due to pain and weakness.
- Bowel or Bladder Changes (in rare cases): Severe compression of the spinal cord in the lumbar region can lead to problems with bowel or bladder function. This is a medical emergency and requires immediate attention.
Should you get imaging for a disc herniation?
The choice of imaging for evaluating a lumbar disc herniation depends on the specific circumstances and the preferences of the healthcare provider. The most common imaging modalities used to diagnose a herniated lumbar disc:
- Magnetic Resonance Imaging (MRI): MRI is considered the gold standard for visualising soft tissues, including the intervertebral discs and spinal nerves. It provides detailed images of the spinal cord, nerve roots, and discs. MRI can show the size, location, and extent of a disc herniation, as well as its impact on nearby structures.
- Computed Tomography (CT) Scan: CT scans use X-rays to generate detailed cross-sectional images of the spine. While CT scans are excellent for visualizing bones, they are less effective at showing soft tissues like the intervertebral discs compared to MRI.
Typically, if there is a suspected herniated lumbar disc, imaging is worthwhile to confirm a diagnosis of an acute injury, particularly in the presence of neurological symptoms. This can aid us in setting up good expectations about the course of treatment and pain experience. A GP referral is required for a CT scan, however an MRI referral can come from your GP or physiotherapist.
Risk Factors for developing a herniated disc.
Several factors can increase the risk of developing a herniated disc. These include:
- Age: Herniated discs are more common in older adults. As people age, the discs in their spine naturally lose some of their water content, making them less flexible and more prone to injury.
- Genetics: Some studies suggest that there may be a genetic component to disc problems. If a person’s family has a history of herniated discs, they may be at a higher risk.
- Excess Body Weight: Being overweight or obese can put extra stress on the spine, increasing the risk of disc problems.
- Gender: Men are more likely than women to develop herniated discs, especially in younger age groups.
- Smoking: Smoking can reduce blood flow to the discs, leading to faster degeneration and potentially increasing the risk of herniation.
- Sedentary Lifestyle: Lack of regular exercise and physical activity can weaken the muscles that support the spine, making it more susceptible to injury.
- Trauma or Injury: Acute injuries, such as a fall or a car accident, can cause immediate disc herniation.
- Degenerative Disc Disease: Pre-existing conditions like degenerative disc disease, which involves the gradual wear and tear of the discs, can increase the likelihood of a disc herniation.
It’s important to note that while these factors can increase the risk, they don’t guarantee that a person will develop a herniated disc. Additionally, some individuals may experience a herniated disc without any obvious risk factors.
What are the treatment options for a disc herniation?
Treatment for a disc herniation can vary based on the severity of the condition, the specific symptoms, and individual circumstances. Here are some common treatment options:
- Rest and Activity Modification: Avoiding activities that exacerbate symptoms and allowing the body time to heal can be beneficial.
- Physical Therapy: Specific exercises and stretches can help strengthen the core and back muscles, improve flexibility, and help you with pain relief.
- Pain Management: Over-the-counter or prescription medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, may be used to manage pain and inflammation.
- Heat or Cold Therapy: Applying heat or cold packs to the affected area can help alleviate pain and reduce inflammation.
- Epidural Steroid Injection: These injections deliver anti-inflammatory medication directly into the area around the affected nerve to reduce pain and inflammation. The injection is given under ultrasound guidance into your lower lumbar spine where the bulging and inflammation has developed. This should be a careful consideration/decision made by you and your medical team.
- Pain Relievers: Depending on the severity of pain, doctors may prescribe stronger pain medications, including opioids, for a limited period. However, opioids have been found to be relatively infective for acute lower back pain and should not be the first line treatment.
- Muscle Relaxants: These can help relax muscles that may be causing discomfort or muscle spasm.
- Nerve Pain Medications: Drugs like gabapentin or pregabalin may be prescribed to address nerve-related pain.
All medication use should be discussed thoroughly with your GP.
Surgical treatment in most cases should not be presented as your first option, but in some cases may be warranted. Types of surgery include:
- Microdiscectomy: This is a surgical procedure where the portion of the herniated disc causing nerve compression is removed. It’s often performed when conservative treatments haven’t provided relief.
- Laminectomy: In some cases, a larger portion of the disc may need to be removed, along with a small part of the vertebral bone.
- Artificial Disc Replacement: In select cases, a damaged disc may be replaced with an artificial one.
- Fusion Surgery: It involves fusing two or more vertebrae together to stabilise the spine.
Acupuncture and Alternative Therapies:
Techniques like acupuncture, massage, and other alternative therapies may offer relief for some individuals. Note that this may give you pain relief but will not facilitate the healing process.
Maintaining a healthy weight, regular exercise, and adopting proper ergonomics can help prevent further disc issues, or aid you in being more comfortable returning to work.
It’s important to note that the best treatment plan depends on the individual case, and it’s essential to consult a healthcare professional for a thorough evaluation and personalised recommendations. They can provide guidance on the most appropriate course of action based on the specific diagnosis and circumstances.
What does Physical therapy do?
Physical therapy can be a crucial component of treatment for a herniated disc. In Many cases, taking a conservative approach can avoid all need for surgery immediately and long term. As physiotherapists, we aim to improve strength, flexibility, and overall function, while also helping to alleviate pain and reduce the risk of future injuries. Typical things to expect from a physiotherapist plan include:
Education and Understanding:
Physical therapists will educate the patient about their condition, explaining what a herniated disc is, how it can affect the body, and what to expect during the recovery process. We are typically the ones to try and de-threaten the injury as going through doctors, specialists and scans can be a very worrying experience.
Pain Management Techniques:
Techniques like heat or cold therapy may be used to help reduce pain and inflammation in the affected area. Manual techniques may be applied by the physical therapist to help alleviate muscle tension and discomfort.
- Core Strengthening: Exercises to strengthen the abdominal, back muscles… but really just all the muscles, the whole body needs some love.
- Flexibility and Range of Motion: Stretching exercises can help improve flexibility in the spine and surrounding muscles.
- Aerobic Conditioning: Low-impact activities like walking or swimming can promote cardiovascular fitness without putting excess strain on the back, but still promote a good amount of movement for the spine and body.
- Posture Training: Techniques for maintaining proper posture can help relieve pressure on you back in the short term.
Hands-on techniques, such as mobilisation and manipulation, may be used to improve joint mobility and reduce pain.
This is a controversial topic and for the most part, passive modalities such as Ultrasound and TENS have been avoided from therapists as it is strongly unsupported by the current body of research.
Therapists may work with the patient on specific movements or activities that are relevant to their daily life or work, helping them regain functionality.
Home Exercise Program:
Physical therapists often provide the patient with a set of exercises to perform at home. Consistency with these exercises is crucial for long-term improvement. Home exercises are unfortunately very important for recovery.
Progress Monitoring and Adjustments:
The physical therapist will regularly evaluate progress and may modify the treatment plan based on the patient’s response to therapy.
What is involved in a physical therapy assessment?
A physiotherapist’s assessment of a disc herniation involves a comprehensive evaluation to understand the nature and extent of the condition. Here are the typical steps a physiotherapist might take:
Medical History and Initial Discussion:
The physiotherapist will begin by discussing your medical history, including any previous spinal conditions, surgeries, and any current symptoms or limitations. We mostly want to find out what has happened and make sure we can rule out any red flags/sinister conditions.
The physiotherapist will ask about your specific symptoms, including the location, nature, and intensity of pain, as well as any radiating symptoms like numbness or tingling. We want to know how these symptoms are affecting you and how they are interfering with your normal daily life.
Physical exam and neurological exam:
This may involve observing your posture, gait, and movement patterns. The physiotherapist will assess how the disc herniation is affecting your ability to move!
In addition, if there are signs of neural compromise, a physiotherapist will want to assess how well the spinal nerve is receiving/sending information, as well as if there is any possible compromise to the spinal canal.
The typical examination to assess the nerve roots include your reflexes, sensation and leg strength. If any or all of these are diminished or affected, then close monitoring is appropriate to make sure they return to pre injury function.
Based on the assessment, your physiotherapist will develop a personalised treatment plan. This may include a combination of manual therapy, exercises, modalities, and education on self-management techniques.
Goals should be established to track progress and measure the effectiveness of the treatment plan. These goals may relate to pain reduction, improved function, or specific activities you want to resume.
Symptomatic lumbar disc herniations are never a straight forward case and will generally vary from person to person. Our anecdotal and research based opinion would say that:
- Pain can be a very horrible experience but is not indicative of the severity of your injury, nor seriousness of injury. Significant pain relief can be difficult in the first 4-6 weeks.
- Imaging is not necessary but can help to facilitate our expectations
- Movement is Necessary and important!
- Spine surgery CAN be avoided! A lumbar disc herniation can sound and feel very unnerving, but the prognosis for recovery without spine surgery is very promising.
If you have had a prior disc bulge or herniation, are worried about your back pain or have a new injury, our experienced team of physiotherapists can help you!