lumbar Disc herniation is a very widespread pathology and suffered by many people. In this article I am going to try to explain what it is, how and what causes can generate it, as well as its medical and physiotherapeutic treatment for the typical case of low back pain due to a lumbar disc herniation (although many of the considerations that I comment on are applicable in case of cervical disc herniation).
What is a spinal disc?
Many times we hear relatives and acquaintances say that they have one or several herniated discs, they may even have detected one for us, but do we really know what it is and what it entails? Do we know what an intervertebral disc is? Do we know what we should and should not do in these situations?
Between the vertebrae there are some cartilaginous discs filled with gelatinous substance that serves as cushioning and fixation, as well as allowing slight movements between them.
The ring is made up of two parts:
- A peripheral part, the annulus fibrosus, is a succession of concentric fibrous layers that enclose the nucleus. In young people it prevents the exit of the substance from the nucleus.
- A central part, the nucleus, gelatinous substance, transparent and composed of 88% water. There are no vessels or nerves within the nucleus.
A simile can be made with a flattened balloon filled with gelatin or silicone. This disc is specially designed to support the loads of the spinal column, dissipating the loads and weights of the body between its core.
What is a lumbar disc herniation?
A disc herniation is, as its name indicates, a herniation or exit of the contents of the interior of the vertebral disc (gelatinous pulpous nucleus) to the outside, compressing different noble structures such as nerves or nerve roots, generating low back pain or what is the same lumbar pain.
At a graphic level and so that everyone can understand the injury mechanism, if we compress this ball or crush it intensely and sustained over time, the fibrous walls that house the contents inside can weaken and crack, and at a given moment this can crack and cause the contents of this balloon (that jelly or silicone) to spill outwards in a sudden movement.
The herniation of the nucleus pulposus can compress either the spinal cord, if it is a central hernia, or the nerve root found on both sides of the vertebra causing reflex contracture of the muscles in the area, and as a consequence generating low back pain with its different symptoms in the leg, (if it is a lumbar disc herniation) or neck pain with its different symptoms in the arm, (if it is a hernia cervical disc).
How an intervertebral disc works and how a disc herniation occurs
In this video we show you how the functioning, anatomy and physiology of an intervertebral disc is and we tell you how it happens and how a ruptured disc or disc herniation occurs:
As we age, the body suffers from dehydration, which also affects the discs, limiting their protective capacity, causing disc degeneration. The impacts cannot be absorbed and the wear of the vertebrae is accelerated.
Sustained or repetitive stresses, pressures and impacts can degenerate the annulus fibrosus of the disc, and produce a tear, deformation or rupture of the annulus fibrosus that will allow the nucleus pulposus to come out.
Signs and symptoms of a herniated disc
Depending on the degree of displacement, it will cause one symptom or another:
- Grade I : no neurological deficit.
- Grade II : proprioception deficit.
- Grade III : non-ambulatory paresis.
- Grade IV : non-ambulatory paresis and signs of urinary retention.
- Grade V : Non-ambulatory paresis, urinary retention, and no deep sensation.
Typical symptoms may be a feeling of numbness in the leg in case of lumbar hernia or in the arm in cervical hernia, sensation of cramp, tingling, loss of sensitivity, loss of strength in the extremity and pain in different degrees (to which known as low back pain) in addition, the examination can show a loss of reflexes and an alteration in body posture.
In short, the severity of a herniated disc is marked by the functional disability it generates for the patient, that is by symptoms fundamentally based on pain, loss of strength and changes in sensitivity. However, on many occasions performing a nuclear magnetic resonance and some other complementary test such as an electromyography, is in general a complementary factor, although in some cases, especially in the most severe ones, it is a determining factor to judge the severity of a herniated disc and its eventual surgical approach.
Therefore, the conjunction of all these data plus the evolution of the process over the weeks and months following the appearance of the process, will determine the treatment of a herniated disc.
Other considerations to take into account:
- Disc herniations usually occur in the lumbar region (95% L4-L5 and L5-S1). Another fairly common location is the cervical region (C5-C6, C6-C7).
- The hernia can not only cause low back or neck pain but can also alter the strength, sensitivity and control of the sphincters, depending on its location.
- Between 30% and 50% of healthy people have one or more herniated discs and do not know it, because they do not cause any problems. Even when there is low back pain or neck pain, it is normal that it can be resolved without operating on the patient, using other treatments.
- The symptoms of a herniated disc can range from nothing at all to symptoms that are very disabling and very incompatible with daily life.
Normally a herniated disc should not be operated on unless:
- There is very intense and limiting pain, which worsens or does not improve after treatment. It must be an irradiated pain that follows a specific path accompanied by alterations in sensitivity, strength or reflexes, for example to the leg, if it is a lumbar disc herniation, or to the arm if it is a cervical disc herniation.
- Low back pain and neck pain decrease with rest.
- Electromyography with signs of root involvement.
- MRI with objective lesion.
- Loss of sphincter control (inability to control urine or stool).
Causes of a herniated disc
When assessing the causes of a herniated disc, mechanical factors such as repetitive exercises, poor posture. In fact, these factors are always present. However, there are more complex and important causal factors that may actually be at the root of the problem. These deeper and more real causes are subordinated by simpler, more typical and tangible justifications such as a bad posture, a bad gesture.
Nothing could be further from the truth, these mechanical factors are, in most cases, the straw that breaks the camel’s back, the last triggering factor but far from it the primary cause of the injury, this cause is usually more complex, multifactorial and deep, which generates the breeding ground that will end up weakening the structures of our back, and that will facilitate that by simple routine gestures, an intervertebral disc designed to withstand large loads gives way, injuries such as herniated discs or protrusions arise and low back pain or a cervicalgia.
These secondary and “hidden” factors may be related to alterations in visceral functioning, prolonged work or emotional stress, poor diet, lack of exercise or excessive sedentary lifestyle, in which in most cases all these added factors are present in various proportions.
What is a lumbar disc herniation and what are its symptoms and causes?
A herniated disc is a medical condition that affects the spine in which a tear in the fibrous outer ring of an intervertebral disc allows the nucleus pulposus to protrude beyond the damaged outer rings and causes low back pain:
Non-conservative or surgical treatment: How is the operation or surgery of the herniated disc?
In the case of herniated discs in the cervical area, surgery with an anterior approach is proposed, that is, the cervical vertebrae will be accessed from the front of the neck. From there they will remove the disc (discectomy) replacing it with a prosthesis welded to the vertebrae with a titanium plate (arthrodesis). If only the nucleus pulposus is removed, we will be talking about a nucleotomy, and it would also be replaced by a prosthesis. There may be the possibility that instead of removing, ozone is injected to help the reabsorption of the gelatinous substance.
Lumbar disc herniations can be approached in different ways depending on the characteristics of the patient’s injury. A laminotomy can be performed, which consists of enlarging the size of the conjunctive foramen (hole through which the nerve root exits), or removing that area of bone (laminectomy) to release pressure on the nerve and eliminate low back pain. They also usually perform arthrodesis in the lumbar area.
Conservative treatment of a disc herniation: things that can be done with physiotherapy
Before any type of surgical or minimally invasive treatment, a physiotherapeutic treatment of the herniated disc is indicated. By means of a good anamnesis, supported by a correct exploration and evaluation of the patient, we will know how to assess the causes of the disc injury and the implication of all these added factors described above. In this way, several remedies must be put in the face of a multifactorial problem. Trying to treat only with manual therapy for 45 minutes a day, in the face of a deep-seated and prolonged problem, is undoubtedly a strategy that remains eminently scarce. Therefore, knowing what factors are present and trying to change habits, prescribing therapeutic and physical exercise, changing toxic habits, and involving the patient in the evolution of the process, will multiply the chances of success.
The short-term treatment goals for the acute phase after surgery will be:
- Decrease pain.
- Reduce the hypertonia of the lumbo-pelvic muscles.
- Correct general posture.
The techniques applied to achieve them will be:
- mesotherapy or massages:
- Gluteal and pyramidal: to decompress the sciatic nerve and relax the muscles.
- Lumbar: reduce pain and contractures.
- Scar treatment to reduce adhesions and avoid tissue retractions.
- Electrotherapy with analgesic currents TENS.
- Magnetotherapy to increase tissue nutrition and analgesia.
- Thermotherapy: the heat will help improve circulation in the tissues and relax the muscles. (Ex: infrared).
- Exercises in the dry and in the pool. The pool will help you lose your fear of moving due to the degravitation property of water, and the temperature will relax your muscles. If the exercises cause pain down the leg, not the back, then you should stop and stop doing them.
- For the correction of low dorsal kyphosis.
- Lumbar relaxation with ball.
- Strengthen muscles.
The medium-term objectives will be:
- Elimination of low back pain and radiation to the legs.
- Gain functionality in activities of daily living.
We will add these techniques to the previous ones:
- Postural hygiene, both sitting, standing, bending over, lifting weights and performing other activities.
- Stretching: of the spine to gain mobility.
- Lumbar stabilization exercises: activation of the transversus abdominis and pelvic tilt to improve lumbo-pelvic mobility. Teaching of respiratory times to mobilize the diaphragm.
The long-term goals will be:
- Meet and maintain the above objectives.
- Start some sports activity or return to the one that the patient performed before the limitation due to the herniated disc.
With these videos you can learn self-massage and beneficial exercises to take care of your spine if you are suffering from low back pain or neck pain due to a herniated disc.
Lumbar disc herniation – Treatment with exercises, self-massage and stretching
This video is indicated for those people who suffer from low back pain due to a herniated lumbar disc and therefore will focus on this part of the body:
Prevention of a herniated disc
Is it possible to prevent a herniated disc? The answer is yes a herniated disc can be avoided but for this the person must have knowledge of how to take care of the lower back and for this these recommendations:
Correct postural hygiene, in the activities of daily work and sports life, is essential for poor posture, prolonged sitting, repeated movements of trunk flexion, inadequate weight loads, because the intervertebral discs deform before these inadequate movements and there occurs the disc herniation with its respective low back pain or neck pain.
Lumbo-Pelvic Stability (CORE):
Lumbar instability is directly related to low back pain and over time can progress to a herniated disc. Currently hundreds of studies have shown that the stability of the lower back depends on the musculature of the abdominal group and the pelvis, these exercises are highly effective and safe for all types of people, it has been popularized as the “CORE Training” which is applied obtaining great results in patients with post-surgical herniated discs and who suffer from low back pain.
Lumbar mobility and flexibility:
You must have a balance between stability and correct mobility in the lumbar spine, since if it is very rigid it also increases the probability of injury to the lumbar area, for this reason pelvic mobility and lumbar flexibility exercises are also recommended.
A herniated disc is the exit of the interior content of the vertebral disc to the outside while compressing different structures such as nerves or nerve roots. Its treatment is divided into two types: surgical treatment and conservative treatment (physiotherapy). Determining which treatment to use will depend on where the herniated disc is located and the severity of the protrusion.