There are a number of technical differences between disc protrusions, bulges, herniations and prolapses but for the purpose of this article, we’ll group these together as disc herniations. The specific name given to a disc condition reflects mainly the severity of the degeneration and as far as Physiotherapy is concerned, it makes very little difference. We simply aim to get our patients pain-free for as long as possible to avoid surgery and maintain function.
A spinal disc herniation occurs when there is a tear in the outer fibrous ring allowing the soft central portion to bulge out beyond the normal area occupied by a disc. The presence of the posterior longitudinal ligament in the spinal canal ensures that these bulges occur mainly postero-laterally (behind and to either side).
A disc herniation is usually due to degeneration (age related) of the annulus fibrosis but can also result from trauma, heavy lifting or straining and in general the degenerative process is accelerated by poor posture and excessive body weight. The increase in pressure in the discs from standing upright to lifting an object with a rounded back has been found to be in excess to 1 500%!!
A tear in the disc may lead to the release of inflammatory mediators which can directly cause pain even without pressure on a nerve root. The symptoms of a herniation will depend on the location and the types of tissues involved-it can range from little or no pain to unbearable pain in the neck/back with pain radiating into the arms or legs (pinched nerve e.g. sciatica) and the pain is commonly aggravated with coughing or sneezing due to the increased pressure within the body. Other possible symptoms include reflex changes, paralysis, paraesthesia (abnormal sensations), muscle weakness, tingling and numbness. The symptoms may vary from time to time but is often continuous.
95% of all disc herniations occur at the L4/5 and L5/S1 levels (lower lumbar region). Symptoms from these herniations may include sensations in the lower back, buttocks, hips, genital region and anywhere along the legs (including sciatica). The second most common levels are C5/6 and C6/7 which may result in symptoms at the back of the skull, the neck, shoulder blades, shoulder joints and down the arms. Thoracic herniations are uncommon due to the stability offered by the rib cage.
The danger of disc herniation is if the symptoms are on both sides of the body(both arms/legs) or if there is genital numbness or pins and needles. It means that it is likely that the pressure is not on a nerve root but on the actual spinal cord (Cauda equina). This needs to be assessed and treated immediately as it may result in paralysis or bladder/bowel and sexual dysfunction-do NOT be ashamed of speaking to your Physiotherapist/doctor about these symptoms! Cauda equina is a medical emergency!
A clinical diagnosis can be made by a Physiotherapist based on a patient’s history, symptoms and physical assessment but the presence/absence of disc pathology can be confirmed by MRI while x-rays are often also helpful to rule out other possible causes of the pain.
Treatment to relieve the symptoms from disc degeneration include anti-inflammatory medication, cortisone injections and Physiotherapy. The Physiotherapy treatments may include correction of biomechanics, posture and lifting habits, bracing or strapping to relieve pain and support the affected segments, myofascial release to ease the related muscles spasms, traction to reduce the pressure on the discs and rehabilitation to improve the core stability to avoid re-injury.
Surgery is usually considered only as a last resort for pain relief or if a patient shows a progressive neurological deficit.
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