LUMBAR DISC HERNIATION

Lumbar disc herniation (LDH)

is a common low back disorder. It is one of the most common diseases that produces low back pain and/or leg pain in adults. A herniated disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. This herniation process begins from failure in the innermost annulus rings and progresses radially outward. The damage to the annulus of the disc appears to be associated with fully flexing the spine for a repeated or prolonged period of time. The nucleus loses its hydrostatic pressure and the annulus bulges outward during disc compression. Other names used to describe this type of pathology are: prolapsed disc, slipped disc or spinal disc herniation, herniated nucleus pulposus and discus protrusion.

It is a medical condition affecting the spine in which tear in outer fibrous ring of IV disc allows soft central portion to bulge out beyond the damaged outer ring. This condition occurs when soft center of spinal disc pushes disc through a crack in the tougher exterior casing. It occur rarely in children, and are most common in young and middle-aged adults. A herniation may develop suddenly, or gradually over weeks or months.

  • The management of disc herniation requires an interprofessional team. The initial treatment should be conservative, unless a patient has severe neurological compromise.
  • Surgery is usually the last resort as it does not always result in predictable results. Patients are often left with residual pain and neurological deficits, which are often worse after surgery.
  • Physical therapy is the key for most patients. The outcomes depend on many factors but those who particpate in regular exercise and maintain a healthy body weight have better outcomes than people who are sedentary.

Types Of Herniations

Protrusion is usually posterolateral into vertebral canal. Protruded disc usually compresses next lower nerve as the nerve crosses the level of disc in its path to its foramen. (Example: protrusion of L5 usually affects S1).

It is less frequent. A protruded disc above 2nd vertebra may compress the spinal cord itself or may lead to Cauda Equina Syndrome.

Nerve root compression happens above the level of herniation. L4 nerve root is most often involved.

Physical Therapy Management

Physical therapy often plays a major role in herniated disc recovery. Involving below key points:

  • Ambulation and resumption of exercise
  • Pain control
  • Education re maintaining healthy weight

Physical therapy programmes are often recommended for the treatment of pain and restoration of functional and neurological deficits associated with symptomatic disc herniation.

Active exercise therapy

It is preferred to passive modalities.
There are a number of exercise programmes for the treatment of symptomatic disc herniation eg:

  • aerobic activity (eg, walking, cycling)
  • directional preference (McKenzie approach)
  • flexibility exercises (eg, yoga and stretching)
  • proprioception/coordination/balance (medicine ball and wobble/tilt board)
  • strengthening exercises
  • motor control exercises MCEs

MCEs (stabilisation/core stability exercises)

They are a common type of therapeutic exercise prescribed for patients with symptomatic disc herniation.

  • Designed to re-educate the co-activation pattern of abdominals, paraspinals, gluteals, pelvic floor musculature and diaphragm.
  • The biological rationale for MCEs is primarily based on the idea that the stability and control of the spine are altered in patients with LBP.
  • Programme begins with recognition of the natural position of the spine (mid-range between lumbar flexion and extension range of motion), considered to be the position of balance and power for improving performance in various sports.
  • Initial low-level sustained isometric contraction of trunk-stabilising musculature and their progressive integration into functional tasks is the requirement of MCEs.
  • MCE is usually delivered in 1:1 supervised treatment sessions and sometimes includes palpation, ultrasound imaging and/or the use of pressure biofeedback units to provide feedback on the activation of trunk musculature.
  • A core stability program decreases pain level, improves functional status, increases health-related quality of life and static endurance of trunk muscles in lumbar disc herniation patients. Individual high-quality trials found moderate evidence that stabilisation exercises are more effective than no treatment.

Different studies have shown that a combination of different techniques will form the optimal treatment for a herniated disc. Exercise and ergonomic programs should be considered as very important components of this combined therapy.

General rules for exercise/ Do and Donts

  • Do exercise slowly. Hold exercise position for slow count of 5. Start with 5 repetition and work up to 10. Relax completely between the repetitions.
  • Do exercise for 10 min twice a day.
  • Care should be taken while doing exercise which can be painful.
  • Exercise daily without fail.

A herniated disk, which can occur in any part of the spine, can irritate a nearby nerve. Depending on where the herniated disk is, it can result in pain, numbness or weakness in an arm or leg.
Many people have no symptoms from a herniated disk. Surgery is usually not necessary to relieve the problem.

Symptoms

Most herniated disks occur in the lower back, although they can also occur in the neck. Signs and symptoms depend on where the disk is situated and whether the disk is pressing on a nerve. They usually affect one side of the body.

If your herniated disk is in your lower back, you’ll typically feel the most pain in your buttocks, thigh and calf. You might have pain in part of the foot, as well. If your herniated disk is in your neck, you’ll typically feel the most pain in your shoulder and arm. This pain might shoot into your arm or leg when you cough, sneeze or move into certain positions. Pain is often described as sharp or burning.

People who have a herniated disk often have radiating numbness or tingling in the body part served by the affected nerves.

Muscles served by the affected nerves tend to weaken. This can cause you to stumble, or affect your ability to lift or hold items.

You can have a herniated disk without symptoms. You might not know you have it unless it shows up on a spinal image.

When to see a doctor

Seek medical attention if your neck or back pain travels down your arm or leg, or if you also have numbness, tingling or weakness.

Risk factors

Factors that can increase your risk of a herniated disk include:

Excess body weight causes extra stress on the disks in your lower back.

People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also can increase your risk of a herniated disk.

Some people inherit a predisposition to developing a herniated disk.

It’s thought that smoking lessens the oxygen supply to the disk, causing it to break down more quickly.

Complications

Just above your waist, your spinal cord ends. What continues through the spinal canal is a group of long nerve roots that resemble a horse’s tail (cauda equina).

Rarely, disk herniation can compress the entire spinal canal, including all the nerves of the cauda equina. Rarely, emergency surgery might be required to avoid permanent weakness or paralysis.

Seek emergency medical attention if you have:

  • Worsening symptoms.
    Pain, numbness or weakness can increase to the point that they hamper your daily activities.
  • Bladder or bowel dysfunction.
    Cauda equina syndrome can cause incontinence or difficulty urinating even with a full bladder.
  • Saddle anesthesia.
    This progressive loss of sensation affects the areas that would touch a saddle — the inner thighs, back of legs and the area around the rectum.

Prevention

To help prevent a herniated disk, do the following:

  • Exercise.
    Strengthening the trunk muscles stabilizes and supports the spine.
  • Maintain good posture.
    This reduces pressure on your spine and disks. Keep your back straight and aligned, particularly when sitting for long periods. Lift heavy objects properly, making your legs — not your back — do most of the work.
  • Maintain a healthy weight.
    Excess weight puts more pressure on the spine and disks, making them more susceptible to herniation.
  • Quit smoking.
    Avoid the use of any tobacco products.

What’s the difference between a bulging disk and a herniated disk?

Answer From Randy A. Shelerud, M.D.

Disks act as cushions between the vertebrae in your spine. They’re composed of an outer layer of tough cartilage that surrounds softer cartilage in the center. It may help to think of them as miniature jelly doughnuts, exactly the right size to fit between your vertebrae.

Disks show signs of wear and tear with age. Over time, disks dehydrate and their cartilage stiffens. These changes can cause the outer layer of the disk to bulge out fairly evenly all the way around its circumference — so it looks a little like a hamburger that’s too big for its bun.

A bulging disk doesn’t always affect the entire perimeter of a disk, but at least a quarter if not half of the disk’s circumference is usually affected. Only the outer layer of tough cartilage is involved.

A herniated disk, on the other hand, results when a crack in the tough outer layer of cartilage allows some of the softer inner cartilage to protrude out of the disk. Herniated disks are also called ruptured disks or slipped disks, although the whole disk does not rupture or slip. Only the small area of the crack is affected.

Compared with a bulging disk, a herniated disk is more likely to cause pain because it generally protrudes farther and is more likely to irritate nerve roots. The irritation can be from compression of the nerve or, much more commonly, the herniation causes a painful inflammation of the nerve root.
If an imaging test indicates that you have a herniated disk, that disk might not be the cause of your back pain. Many people have MRI evidence of herniated disks and have no back pain at all.