Most of us might not be aware the meaning of disc herniation and its causes. What we didn’t know is that this condition is very common for most of those middle-aged adults, both male and female equally. In addition, if your occupation involves sitting in the office all time, then the risk to have disc herniation will be greater. In this article, you will understand about disc herniation in a simple way.
Disc Protrusion, which is known as “Slipped disc” is a condition in which there is a tear in the outer fibrous ring of the intervertebral disc, allowing a soft round gel called nucleus pulposes to bulge out beyond the damaged outer ring, which will then compress the spinal nerve.
One of the common causes is sitting down with trunk bending forward for long period of time or those people who usually work in the desk office. For those who just sit all the time, they have high risk of low back pain compare to those who are usually standing or moving a lot. That is because the pressure in your disc of the spine becomes greater compared to those who just stand especially when you are stooping or bending forward. Your disc has a two-layer: The outer ring we called it the “Annulus Fibrosus” and it surrounds the gel-like content called the “Nucleus Pulposes. When there is a high pressure in the disc, the annulus fibrosis layer is degenerating which eventually there is a tear and the nucleus pulposes will start to get out or in another word bulging and the moment it compresses the nerve, you will start to experience pain and other symptoms. The common area that is usually affected is in the L4-L5 area, which is why most of the people usually complain low back pain, rather than upper or middle back pain.
Stages of Disc Herniation
When you have Disc Herniation, the severity of this conditions depend on what stage is it. There are 4 Stages of Disc herniation which is in order from minor to severe.
- Bulging or Protrusion
This is the mildest form of Disc Herniation which is called Bulging or Protrusion. In here, the bluish gel-like disc called Nucleus Pulposes will start to swell out. However, the layer which surrounds this gel called Annulus Fibrosus hasn’t broke out yet and it is still within the boundaries.
In this condition, the patient usually complains of only Low Back pain without spreading down to the legs.
The disc is starting to move out beyond the boundaries of the layer annulus fibrosus. However, the outer layer hasn’t still broke yet.
In this condition, because the disc is starting to put pressure on the spinal nerve root, the person is starting to have sharp pain that will spread down to the legs known as Sciatica. To know more about Sciatica there is a separate page that is briefly discussed about this problem
The outer layer that surround the gel-like Disc called Annulus Fibrosus had already degenerate and the disc or nucleus pulposes broke out, which mean the disc is getting out of the layer and it is starting to spread out, putting more pressure on the spinal nerve.
It is at this stage, this is where the person will be regularly experiencing Sciatica pain.
This is very similar like extrusion but the only difference is that a tiny fragment of the disc had break out, which separate from the main disc and travel it down toward the space on where the spinal cord is located.
Unfortunately, this is the most severe type of Disc Herniation, and usually, surgery is indicated for this kind of situation.
Below here, I have specifically enumerate which positions will the disc pressure becomes greatest based on the percentage. For Reliability purpose, the sources I got them comes from Physical Therapy Books which I used them when I was a student.
Lying down: 25%
Standing with Bending forward: 150%
Standing with Bending forward and holding weights: 220%
Sitting with your trunk straight: 140%
Sitting with bending forward: 185%
Sitting with bending forward with weights: 275%
Based on those significance above whether you are holding a weight or not, sitting with bending posture has the greatest pressure in your disc, followed by standing with bending posture. But if you manage to maintain your proper body mechanic when you are sitting or standing, the pressure in the disc reduce significantly, which subsequently reduce the risk of disc herniation that induce low back pain.
Because the spinal is being compress, the common symptom is usually sciatica. This is when pain spread down from the back to the lower leg when you bend forward and the pain got relieved when bending backward, we called this “extension biased” since the pain got better when you extend or bend backward. Other symptoms are like tingling or numbness sensation, hyporeflexia and sharp pain in the back.
What will the Physical Therapist or the Doctor examine on you?
When you will be going to the Physical Therapist or the Medical Doctor, the first thing they would do is to perform Physical Examination on you. There are 3 specific kind of examination they will need to perform on you to possibly confirm you might Disc Herniation.
A. Straight Leg Raise Test
In this test, you will be asked to lie down in the mat and he or she will passively lift your leg up with your knee remain straight. Based on the picture above, when you reach 30 to 60 degree, you will start to experience sharp pain on your Low Back. This test is considered positive, and based on this finding it indicate that your nerve is being compressed, which is why you experience this sharp pain.
B. Testing your Reflexes by using Neurological Hammer
The Physical Therapist or the Medical Doctor will be using a Neurological Hammer that will tap your tendons in the Knee, which there will be a reflexes response. If you potentially have a presence of Disc Herniation, the reflexes response will be very weak, and this is what we call Hyporeflexia.
3. Sensory Testing
In this test, they will be checking your sensation in both leg and your back by using either the Cotton for soft touch, the sharp tool for pain, or using its own Thumb for pressure. If you have difficulty sensing them or you feel abnormal sensation such as numbness or tingling, this is considered positive finding.
Will you be asked for an X-ray or MRI for Disc Herniation?
In here you might wonder why do the doctors will require you to have MRI despite your X-ray results remain negative. This is because X-ray is only useful if bones are involved, for instances if you might potentially have Fractures, Osteoporosis or Arthritis. But for MRI on the other hand, the problem is not the bones but rather the Discs, nerve and other soft tissue involvement, which they can only be visualize by MRI.
This is an example of Disc Protrusion that is being done by MRI. As you can see the structures are very detailed which this cannot be seen by X-ray.
There are two ways that your disc herniation will be treated. Either the doctor will prescribe you medication for pain killer or he would refer you to Physical Therapy, which they will teach you how to perform the exercises while you are in the house. You will be instructed to perform exercises that will help relieve the pressure in the nerve and strengthening your back muscle, which will help provide support in the disc, reducing pain.
Also you must remember that when you have sciatica, the source of the problem could not just be from disc herniation, but it could also be you have a tight Piriformis muscle, on which it will compress the nerve on the back of your thigh called sciatic nerve, and by the name itself it causes sciatica.
These are the managements that are being used by the Physical Therapist to help relieve the pain.
1. Stretch the Piriformis muscle
2. Perform McKenzie exercise for low back pain.
3. Aside from the exercises mention above, the Physical therapist will teach you how to perform Dynamic Lumbar Stabilization Exercise. This exercise will help provide stabilization on the muscle of your back, which will help reduce low back pain.
4. Providing education on your proper body mechanic to prevent aggravating the symptoms, such as preventing bending forward or avoid positions that place greater pressure on the disc which they will be taught by Physical Therapist
5. In Physical therapy clinic we usually use a machine called Electrical Stimulator (ES) or Transcutaneous electrical stimulator (TENS) which produce electric like relieving pain, this is very useful and easy to use. Research have shown, that using TENS for relieving pain produce similar effect like pain killer medications.
6. Also in Physical Therapy Clinic, they will be using a machine that will help relieve the pressure on the spine called Lumbar Traction, which will relieve the pain by pulling the disc apart.
7. In some cases, the medical doctor or the Physical Therapist will recommend you to buy a Lumbosacral Belt which will help support your back and relive the pain.
8. In some cases, A manual technique known as Joint manipulation will be performed by Chiropractors, Physical Therapist and even some Physicians who have extensive background on this technique.
Normally in most cases the Disc Herniation are usually relieved by non-operative management such as through Physical Therapy. In some cases if your pain doesn’t get better, Surgery are usually the last option.
In this video this will illustrate a simple concept about Disc Herniation, which can help you understand better. Please remember I do not own this video and the source comes from YouTube through this link