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Disc Information for Patients
This information is for reference use only, and should not constitute a diagnosis.
You go to your family doctor with low back and/ or leg pain and ask about seeing a chiropractor. "Oh, no," says the doctor," they'll try to pop it back into place, which will not only be painful, but make matters much worse." Is this true? What is the chiropractic approach to treating a "slipped disc"? Chiropractic is conservative care, which means it is non-surgical and drugless. In treating low back "slipped discs", most spine experts agree that conservative care should be tried before surgery is considered, except in severe cases.
Chiropractic care has a long history of successfully providing conservative care for disc conditions - and no, chiropractors don't try to "pop a disc back in place".
Hopefully, by the time you're done reading this, you will know this about lumbar spine discs: A: Their Anatomy B: The symptoms of a lumbar disc injury C: How doctors diagnose the condition D: What treatment options are available.
The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form, and is the body's main upright support. The old chiropractic joke (not really funny) is that the spine has two functions: to support the body, and support the chiropractor... (See? Told you it wasn't funny) The section of the spine in the lower back is known as the lumbar spine.
The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back an inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people (about 5-10%) have an extra, or sixth, lumbar vertebra. This condition doesn't usually cause any particular problems, but these people tend to be taller!
It's easiest to think about the disc as a circle of ligament between each vertebra (the bones of the back) in the spine that acts as both a shock absorber and a shock distributor.
Cross section of the lumbar disc
Without discs, which are tough ligaments, the spine simply could not function. Discs are actually made up of concentric rings (like those of a tree) of fibrous material with a tough, gelatinous center. The rings look very similar to those of a tree, hence the name: annular ligaments. When cracks, or fissures, occur in the fibrous rings, the gelatinous material in the center can begin to push out.
Discs don't really "slip". Instead, they bulge, herniate, protrude, or rupture. Saying a disc has "slipped" does, however, suggest that something has "slipped out" and is not where it's supposed to be, which is what exactly happens in disc injuries. The low back disc is almost always the result of a cumulative process, versus a single 'event'. As is often the case with joint and back injuries, the problem starts small and then builds until it becomes symptomatic. It's a little corny to talk about "the straw that broke the camels back", but it gets the point across.
For example, a patient sneezes/ picks up a pen/ washes a dog/ just sat up out of bed/ had sex/ fell snowboarding, etc. and experiences sudden back pain, proceeding to leg pain. However, the sneeze et.al didn't cause the disc to "slip," but represents the final "straw" in a much longer process. Factors that precede the pain and symptoms of disc injury include disc dehydration, unusual stress on the disc secondary to disturbed mechanics, and too much load on the disc.
The discs separate the vertebrae, and are made of connective tissue of a material called collagen, and when a disc is cut in cross section, the layers of connective tissues look very much like rings on a tree. In fact, the layers are called annular fibers, like a tree's. These layers help the disc withstand tension and pressure.
A disc is made of two parts. The center, called the "nucleus pulposis" (It means "pulpy center" in Latin) is spongy, a little more than a rubber ball. It provides most of the disc's ability to absorb shock. The nucleus is held in place by the annular rings.
Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity. They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting. Perhaps the most interesting feature about discs is that they have no blood supply. In fact, the discs are the largest avascular structure in the human body. Instead of blood supply, the disc 'sucks up' water during sleep, and squeezes it out when loaded. Discs depend on water to keep their height and perform efficiently. When we're young, discs have their own circulation that helps keep them hydrated. As we get older, this circulation ends and the spine must move so that water can be drawn into the discs. If discs become dehydrated and lose their height, they're vulnerable to cracks and fissures. The loss of water in the discs is the primary reason why people get shorter as they age.
Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc. Chiropractors are especially interested in seeing how injuries in one part of the body relate to the mechanical system of the body as a whole. We look at injuries specifically, but they also try to determine in what way an injury is the outcome of disturbances elsewhere in the body.
The spine functions as a whole, so if we have mechanical disturbances in one part of the spine, even as far away from the low back as the neck, it can influence conditions in another area of the spine. Imbalances in the pelvis, problems in the sacroiliac joints, low back facet fixations, as well as joint restrictions in the mid back and the neck, even the feet and ankles can contribute to the process of disc degeneration and eventual injury, and can explain why your chiropractor adjusts you, not only at the low back level, but elsewhere, as well.
Vigorous, repetitive bending, twisting, and lifting can place abnormal pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus, leading to herniation.
A lumbar disc can also become herniated during an acute (sudden) injury. Lifting with the trunk bent forward and twisted can cause a disc herniation. A disc can also herniate from a heavy impact on the spine, such as falling from a ladder and landing in a sitting position.
Herniation causes pain from a variety of sources. These are mechanical pain, inflammation pain and neurogenic pain. Mechanical pain comes from the parts of the spine that move during activity, such as the discs and ligaments. Inflammatory pain occurs when the nucleus squeezes through the annulus. The nucleus normally does not come in contact with the body's blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. Neurogenic pain occurs when there is direct pressure against a spinal nerve. Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve, in pretty regular patterns.
It's interesting to note that disc damage is typically a problem of middle age... Youths haven't traumatized their disc enough to have them herniate, and the elderly's discs are dried out to the extent that they don't 'goop' anymore.
The disc can be thought of more as a grape in young people...
and more like a raisin in the elderly.
How about a chocolate cream filled doughnut analogy? Whatever works!
If you are actually reading this because Dr. Carr told you to... you probably already know.
Many cases of lumbar disc herniation result from degenerative changes in the spine. The changes that eventually lead to a disc herniation produce symptoms gradually. At first, complaints may only be dull pain centered in the low back, pain that comes and goes over a period of a few years. Doctors think this is mainly from small tears in the annulus. Larger cracks in the annulus may spread pain into the buttocks or lower limbs.
When the disc herniates completely through the annulus, it generally causes immediate symptoms, with sharp pain that starts in one hip and shoots down part or all of the leg. Commonly, patients no longer feel their usual back pain, only leg pain. This is likely because painful tension on the annulus releases when the nucleus pushes completely through. This usually occurs in the morning, and often patients will say they got out of bed, and then "X happened" and it was like being hit by lightning".
Disc herniations produce inflammation when the nucleus comes in contact with the body's blood supply (mentioned earlier). The inflammation can be a source of throbbing pain in the low back and may spread into one or both hips and buttocks.
A herniated disc can press against a spinal nerve, producing symptoms of nerve compression. Nerve pain follows known patterns in the lower limbs. It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes.
Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs. If this happens, a person's reflexes slow. The muscles controlled by the nerve weaken, and sensation in the skin where the nerve goes is impaired.
Rarely, symptoms involve changes in bowel and bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency!!. If the pressure isn't relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.
How do doctors diagnose the problem?
Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. These will include questions about where you feel pain and whether you have numbness or weakness in your legs. Your doctor will also want to know what positions or activities make your symptoms worse or better. Doctors rely on your report of pain to get an idea which disc is causing problems and if a nerve is being squeezed.
Then the doctor examines you to determine which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested. Often disc problems can be diagnosed as you walk through the door. Often times patients say they are "bent" in what we doctors call antalgic posture. Often merely leaning in the opposite way increases pressure to the point that it's intolerable. Even if the doctor simply raises the leg it can cause excruciating pain (the straight leg raising test). If coughing, spitting, sneezing or bearing down cause really sharp pain, that's another sign of disc injury (Valsalva's maneuver).
There are plenty of tests that the doctor can do, all with funny names ; slump test, lasague's, siccard's, braggard's. The names aren't important.. their findings are. They all essentially increase the pressure on the front part of the disc, shoving the disc material back onto the spinal nerve roots or cord.
X-rays are of limited help in diagnosing disc herniations, but are usually recommended to rule out any other kind of hard pressure on the nerves. Discs don't actually show up on X-rays. However, doctors can tell if the space between the vertebrae is smaller than normal. This can be an indication that wear and tear on one or more discs is causing problems. However, many peoples' X-rays show degeneration of the discs. This is because degeneration in the discs is part of aging, like skin that wrinkles with time without proper care. Chiropractic care is an excellent way to keep this degeneration from occurring.
We typically use the analogy of a healthy disc to be a juicy grape, and a degenerative disc to be a raisin...this analogy works because the degeneration of discs is usually simply a loss of water from the disc. The interior nucleus is actually more like the consistency of a "super ball" rubber ball that can be bought in vending machines.
Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body's tissue. The image can show if a herniated disc is putting pressure on a spinal nerve.
The diagnostic test that we recommend first, however, is magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether a herniation is present. Like the CT scan, this machine creates pictures that look like slices of the area your doctor is interested in. The test does not require special dye or a needle.
Doctors sometimes order a specialized X-ray test called discography. In this test, dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of one or more discs. This test may be used when surgery is being considered to determine which disc is causing problems, and we only really recommend it if you are looking at having surgery... it can be pretty painful.
Doctors may also order electrical tests to locate more precisely which spinal nerve is being squeezed. Several tests are available to see how well the nerves are functioning, including the electromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if a herniated disc has put pressure on a spinal nerve. Another test is the somatosensory evoked potential (SSEP) test. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels. Doctors will often run these tests before performing surgery for a lumbar disc herniation.
Treatment - Nonsurgical
1. Non Invasive --> 2. Drugs ---> 3. Surgery
Unless your condition is causing significant problems or is rapidly getting worse, almost all doctors will begin with nonsurgical treatment. There is a good reason for doing this- failed low back surgery rates can be as high as 25%.
At first, your doctor may want your low back immobilized. Keeping the back still for a short time can calm inflammation and pain. This might include a day or two of bed rest. Lying on your back, with your legs raised, can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. In rare cases in which bed rest is prescribed, it is usually used for a maximum of two days.
One of the "latest" treatments is lumbar decompression... its a really expensive machine that costs a lot to use and makes a lot of money for the doctor. Today's machines are simply an outgrowth of that technology, but far slicker with TV screens, music, and a great marketing.
Did you know?
Dr. Carr had a lumbar decompression unit in college; it was called the "Inertial Extensilizer", and we used to laugh about it during our adjusting sessions. Who knew it'd be so popular?
Information, and lots of it, is the 'number one' treatment for disc herniations... if you know how the disc operates and what makes it better and worse, then most people can live with the condition for the rest of their lives. Basically, it comes down this:
- Moving the nucleus material back into the disc space is our (and your) number one priority.
- Often, there is a mantra we force our patients to memorize: traction and extension.
- Any motion that aids in the maintenance of these motions will be helpful to you.
A back support belt is sometimes used for patients with lumbar disc herniation. The belt can help lower pressure inside the problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to atrophy (shrink).
Extension is pretty easy to come by: buy a physioball, lay back over it. 55cm balls work best up to about 5'7', then we recommend a 65cm ball up to about 6'0', then a 75cm ball for anyone above that height.
Traction is a very difficult thing to accomplish, requiring you to hang upside down by your hips or legs. Dr. Carr recommends the Invertrac unit, shown to the right: It looks scary, but it's pretty easy to use, and it's cheap: Only 325 bucks.
This is possibly the cheapest, easiest way to get traction of the lumbar spine.
Doctors prescribe certain types of medication for patients with lumbar disc herniation. At first, you may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Severe symptoms that don't go away may be treated with narcotic drugs, such as codeine or morphine. But narcotics should only be used for the first few days or weeks because they are addictive when used too much or improperly. Muscle relaxants may be prescribed if the low back muscles are in spasm. Pain that spreads down the leg is sometimes relieved with oral steroids taken in tapering dosages.
Surgery is, of course, a last resort. There are numerous means of performing surgery on a disc, from 'minimally invasive' to 'nuts, bolts and screws' surgery. Lumbar surgery actually has a poor success ratio, with the result being "failed low back surgery" and even surgeons are hesitant to recommend cutting before all other options are tried.
Did you know?
- If you go under the knife for lumbar disc surgery and you come out in the same condition that it is considered a "successful surgery"?
- Smoking can inhibit the process of healing after lumbar spine surgery, and some doctors won't do the surgery until you've quit?
Treatment should begin with the least invasive methods first.
The doctors of Dynamic Chiropractic Clinics are very familiar with these cases, and have successfully treated disc patients with great results. There are no guarantees, however' and much of the treatment must be done at home. Your willingness to do the exercises will make a huge difference in your outcome.
This does not constitute or substitute for an actual diagnosis in a doctor's office. For that we recommend seeing a doctor, in a clinic.
If you have any questions at any time, please do not hesitate to call Dr. Carr at 206-343-3325.