Herniated Discs and Disc Protrusion Therapy

Here we investigate the common condition of spinal disc herniation, also known as disc protrusion and bulging disc.

Spinal Anatomy

Discs, also known as intervertebral discs, are soft, rubbery pads found between the spinal bones (vertebrae) of the spinal column. The spinal canal is a hollow space in the middle of the spinal column that contains the spinal cord and nerve roots. The discs between the vertebrae act as shock absorbers as well as allow the spine to move.

Taking a closer look at the structure of the intervertebral disc we observe that the disc is composed of a thick outer ring (known as the annulus) and an inner gel-like substance – the nucleus pulposis.

Can a disc “slip” out of place”?

An often held misconception is that the discs in your spine can “slip”…however a “slipped disc” is anatomically impossible!  Rather, what is actually being referred to is a herniated disc – a common source of pain in the neck, lower back, arms, or legs.

Cause of Spinal Disc Herniation

A disc herniates or ruptures when part of the centre nucleus pushes through the outer edge of the disk towards the spinal canal. Usually, but not always, this imparts pressure onto either the spinal cord or the exiting spinal nerve roots. Spinal nerves are extremely sensitive to even slight amounts of pressure, which can result in pain, numbness, or weakness in one or both legs.

Risk Factors/Prevention of Disc Herniation

In children and young adults, spinal discs have high water content. However, as people age, the water content in the discs decreases and the spinal discs become less flexible. The discs begin to shrink and the spaces between the spinal vertebrae get narrower. Conditions that can weaken the disc include:

* Improper lifting
* Smoking
* Poor spinal posture
* Excessive body weight that places added stress on the discs (in the lower back)
* Repetitive strenuous activities

It stands to reason that if you assume a healthy body weight, engage in regular activity and safe manual handling practices that you can significantly reduce the likelihood of disc herniation.

Lower Back Symptoms of Disc Herniation

Low back pain affects 80% of people at some stage during their lives. Pain alone is not enough to recognise a herniated disc. The most common symptom of a herniated disc is sciatica — a sharp, often shooting pain that radiates from the buttocks down the back of one leg. Sciatic nerve pain is caused by pressure on the spinal nerve in the lower lumbar spine.

Other symptoms include:

* Weakness in one leg
* Tingling (a “pins-and-needles” sensation) or numbness in one leg or buttock
* Loss of bladder or bowel control (If you also have significant weakness in both legs, you could have a serious problem and should seek immediate attention.)

Neck Symptoms of Disc Herniation

As with lower back pain, neck pain is also common. When pressure caused by disc herniation is placed on a nerve in the neck, it causes pain about the muscles between your neck and shoulder (trapezius muscles). Often, the pain may radiate or shoot down the arm. The pain may also cause headaches in the back of the head.

Other symptoms include:

* Weakness in one arm
* Tingling (a “pins-and-needles” sensation) or numbness in one arm
* Loss of bladder or bowel control (If you also have significant weakness in both arms or legs, you could have a serious problem and should seek immediate attention.)
* Burning pain in the shoulders, neck, or arm

Diagnosis of Spinal Disc Herniation

To diagnose a herniated disc, your doctor or physiotherapist will ask for your complete medical history. This usually includes a full physical and neurological examination as well as spinal xrays which can reveal degenerative spinal changes.

MRI (magnetic resonance imaging) or CT (computed tomography) scans may also be required to accurately diagnose and determine the spinal nerves and disc levels involved.

Treatment of Disc Herniation

Nonsurgical Treatment

Nonsurgical treatment is effective in treating the symptoms of herniated discs in more than 90% of patients. Most neck or back pain will resolve gradually with simple measures.  Gentle Physiotherapy care can assist in relieving muscle tension and pain as well as increasing muscle and joint flexibility.  Your Doctor or Physiotherapist is also likely to recommend a combination of the following advice:

* Postural and proper manual handling technique
* Rest and over-the-counter pain relievers
*Muscle relaxers, analgesics, and anti-inflammatory medications
* Cold compresses or ice can also be applied several times a day for no more than 20 minutes at a time.
* After any spasms settle, gentle heat applications may be used.

Any physical activity should be slow and controlled…especially bending forward and lifting. This can help ensure that symptoms do not return-as can taking short walks and avoiding sitting for long periods. For the lower back, exercises may also be helpful in strengthening the back and abdominal muscles. For the neck, exercises or traction may also be helpful. To help avoid future episodes of pain, it is essential that you learn how to properly stand, sit, and lift.

If these nonsurgical treatment measures fail, epidural injections of a cortisone-like drug may lessen nerve irritation and allow more effective participation in physical therapy. These injections are given on an outpatient basis over a period of weeks.

Surgical Treatment

Surgery may be required if a disc fragment lodges in the spinal canal and presses on a spinal nerve, causing significant loss of function. Surgical options in the lower back include microdiscectomy or laminectomy, depending on the size and position of the disc herniation.

In the neck, an anterior cervical discectomy and fusion are usually recommended. This involves removing the entire disc to take the pressure off the spinal cord and nerve roots. Bone is placed in the disc space and a metal plate may be used to stabilise the spine.

For some patients, a smaller surgery may be performed on the back of the neck that does not require fusing the bones together.

Each of these surgical procedures is performed with the patient under general anesthesia. They may be performed on an outpatient basis or require an overnight hospital stay. You should be able to return to work in 2 to 6 weeks after surgery.

Post surgical Physiotherapy

Physiotherapy after your operation looks at normalising your range of movement and strengthening the muscles that provide postural support to your spine.A graded series of exercises will be prescribed that will strengthen your core and provide flexibility to your healing tissues. As you progress nerve stretches will also be added along with muscle stretches to further optimise your recovery and reduce the chances of further episodes of pain in the future. You will also be advised on correct lifting and postural reeducation as it relates to your work or life style requirements.  Return to the gym or sport will also be discussed in consultation with your surgeon.

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