Get ready to dig in with me to understand this often manageable pathology!!
I have been in private practice for over twenty one years now and I have seen the diagnosis of “Disc Herniation” and all of its varied terminology literally countless times. The patient frequently presents with a sense of dread and doom and our medical culture has labeled this clinical entity with little or no hope and resolution and all too often given few appealing options – surgery being the ultimate solution. Well, if that were true, why is it that many of the cases I evaluate have already endured disc surgery only to find their symptoms return with similar or more intense patterns of pain?? Or how about the low back pain patient that presents with no sciatic pain and MRI reveals a significant lumbar disc herniation??
Let’s first look at the spinal anatomy and correlate the mechanisms of disc pathology and how and why it can cause pain. The lumbar spine is composed of five large vertebrae with two facet joints that interface with the bone below and above. Between the large parts of the vertebrae, the vertebral bodies, are intervertebral discs consisting of fibro-cartilage rings with a pulpy fluid or “nucleus pulposis” that resides in the central portion of the disc matrix. These discs act as cushions or supportive yet flexible mechanisms that also function as dynamic stabilizers of the spinal system. Discs, non-vascular in nature, require movement for nutrition and maintenance for their fluidity. If the lumbar spine becomes rigid with diminished flexibility, the discs begin the process of degradation and dehydration. If this process is allowed to progress, the discs will lose their functional ability and transfer their load carrying talents to the less inclined facet joints and deep erector spinal muscles. This is a dangerous path that often happens insidiously. That is one of the main issues in spinal/pain management as the deterioration process often occurs under the proverbial radar and something “big” happens like a lumbar spine strain/sprain injury and a hornets nest is now awakened. So the treating practitioner is dealt with prioritizing the multiple levels of damage with sequential management strategies. There are muscle spasms and underlying myofascial inflammation, there is facet joint stress and inflammation, there is disc driven pain mechanisms and nerve irritation from various tissues. The “Hot Low Back” is indeed just that and requires techniques to calm down the “fire” and begin a strategy of healing, unwinding the layers of damage and stress mechanisms as well as finding a way to restore function, range of motion, flexibility and core strength. This is why drug therapy has been so appealing in the industry as lower back pain syndromes are very debilitating and most practitioners will not take on the process of addressing the mechanisms of why the low back process began in the first place. It’s easier to just prescribe numbing drugs and hope it “goes away”.
Types of disc driven pain and dysfunction:
- Herniated Disc – this is certainly a pain generator ranging from extremely severe and debilitating to an annoyance. Why the variance? Well, depending on where this mass of disc material protrudes and what tissue it touches depends on the degree of symptom. For instance, if the herniation contacts the descending nerve root emanating from the spinal cord, this will no doubt result in nasty neurological pain with radiation. In some cases, the disc may be large but just graze the nerve root or miss it entirely and result in minimal symptoms.
- Bulging Disc – this can ruin life for a while (4-12 weeks) depending on many factors but typically will resolve with time, appropriate therapy and nutrition. Bulges occur on and off throughout life and during exertional episodes the disc will bulge out and swell and irritate delicate, adjacent nerve tissue causing pain and sciatica. Bulges can progress to herniations if not managed expeditiously. Bulges may retreat but if the disc is already degenerative, it will remain in the bulged position causing intermittent symptoms with periods of quiescence.
- Desiccated/Degenerative Disc – this condition will ultimately affect everyone as the years accrue but some discs degenerate earlier in life than others due to factors such as lifestyle, smoking, nutrition, body weight, hydration, sedentary work, repetitive stress work, spinal design and physical fitness. Degenerative discs can cause pain axially due to loss of the functional cushion effect that “normal” discs provide. The load stress transfers from the now defunct disc to the poorly equipped compensated facet joints which are not designed for load bearing stress. This causes axial pain and persistent tightness in the lumbar spinal muscles.
- Annular Tear – this pathology typically occurs following a stressful event to the lower back that includes some form of torsion. Some of the rings of fibrocartilage of the disc actually tear and this leads to an escape of fluid from the nucleus pulposis that can actually create a noxious, chemically mediated nerve pain. Annular tears typically occur to degenerative discs as they are poorly equipped to handle any torsion due to their dehydration. Healing windows for annular tears can take up to one year. The tear will form scar tissue but will remain vulnerable.
- Disc Fragment – due to a herniation that actually separates from the disc itself and migrates into the spinal canal can prove disastrous and typically requires surgical removal.
Diagnosing Disc Pathology:
MRI remains the gold standard for diagnosing disc pathology. This imaging can detect the degree of damage and if the disc material is causing nerve irritation or compression. With annular tears, MRI highlights the tear and if there is what is known as a “high intensity zone” of stress/inflammation. With degenerative disc disease, this is easily visualized and a high degree of perspective is revealed as well.
Nutritional Intervention – Increasing omega three fatty acids in the form of cold water fish oil in elevated doses (6-9 grams), proteolytic enzymes (trypsin/chymotrypsin) 3-5 units 3X/day, turmeric/boswellia/ginger in elevated doses via supplementation (Inflavonoid), and celery seed in supplement form to drive down effects from the inflammation are recommended for 30+ days. High levels of Magnesium Glycinate and Malate to support muscle physiology (bowel tolerance then back dose)(this can range from 500mg to 1500mg depending on patient size). Eliminate gluten grains and dairy to additionally support the inflammation process. Increase hydration levels with pure water and consume organic, free range, drug free animal products with vegetables and low glycemic fruits.
Exercise - It is important to continue to find the strength and resolve to exercise through this pathology. Low stress/impact cardiovascular exercise will assist in pain management by elevating endorphins and maintaining strength and conditioning in the body. Pain levels will determine the level and type of activity but even light stretching and recumbent bike will provide benefit. This can be done daily or every other day as tolerated.
Chiropractic – this can be applied to provide corrective support to the structural components of the body. When the frame exhibits proper alignment and has proper joint range of motion and function, the body is more apt to unload the stress from painful disc –nerve issues. Techniques are modified to support the body during this painful condition.
Physiotherapy – Iontophoresis, interferential current therapy, pusled wave ultrasound, ice and flexion/distraction/traction type procedures will promote disc decompression and alleviate nerve irritation.
Myofascial Dry Needling/Cupping Therapy – These techniques combined with above modalities will provide some pain relief and assist the body in it recovery process.
Medical Pain Management – Pain management physicians will often prescribe stronger medicines such as NSAIDs, Narcotics, and radiographically guided injections (Epidurals, Selective Nerve Root Blocks, Ablations etc.) to help with the process.
Home Care – Ice, Rest, bracing, T.E.N.S. and inversion/decompression can all provide relief and assist the body in recovering from this relentless condition.
Surgical Intervention – Neurosurgical evaluation is recommended for recalcitrant cases. On occasion, the disc pathology will not respond to time, conservative management and/or medical intervention and when pain, motor function and/or bladder/bowel function are implicated, surgery might be the best option. Microsurgical techniques are recommended for the pure disc pathology but often times, the lumbar spine has additional complications that may require more invasive solutions. Second opinions are highly recommended with these types of surgical decisions. Typically, most neurosurgeons will recommend exhausting all options prior to surgical intervention so it behooves the patient to exhaust the above protocols before consulting with them.
Final Thoughts – Disc injuries are detectable entities but it’s the complicating concomitant issues that make it difficult to navigate through. It is difficult to remain compliant and patient when nerve pain is basically ruining one’s life. However, the body has a tremendous healing potential and with supportive therapies, target nutrition and medical intervention, most of these debilitating cases will resolve. And, the MRI is a must to visualize this for proper management.