Introduction:

Spinal disc herniation is also known as a slipped disc. [2] When a patient tells me they have a slipped disc, I am immediately sceptical. How do they know this? Who told them? How was it described?

The condition is widely referred to as a slipped disc, but this term is not medically accurate as the spinal discs are firmly attached between the vertebrae and cannot “slip” out of place.

There is an evidence-based criterion for diagnosing disc problems used by all health professionals from Orthopaedic surgeons to chiropractors to osteopaths. It’s imperative to sort fact from fiction, at least the best we can with the resources we have.

Prevalence:

Slipped discs in general account for around 5 to 20 cases per 1000 adults per year. They most commonly affect 30-50 year olds with more women than men (2:1) [6] It is believed around 1-3% of people experience pain and symptoms associated with a ‘slipped disc’. [7] Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. ‘It is believed 25-55 years old have an approximately 95 percent chance of herniated discs occurring at these levels. [9]

The most common region of the human spine to suffer a slipped disc is the low back or lumbar spine. The neck or cervical spine is the next most common. This is due to greater biomechanical forces and load-bearing. The thoracic spine is the least effected. [4,5]

Mechanism:

In the centre of the Lumbar intervertebral ‘slipped lumbar disc’, a gel-like material (nucleus-pulposus) protrudes through cracks in the outer-rings (annulus-fibrosus). This causes degrees of nerve root compression, which then may lead inflammation, pain, numbness or weakness in the back, gluteal region, leg and/or foot. This can significantly impact activities of daily living.[8]

Cause:

It is considered a slipped disc that accounts for less than 5% of people with spinal pain.

Degradation of the anulus fibrosus is suspected to be related to age, trauma, lifting injuries, or straining. Anulus tears are typically at the back and to one side (postero-lateral) mainly from a preventative, supportive structure known as the posterior longitudinal ligament which prevents a purely posterior injury. Once the anulus has torn this is usually predisposed to further tearing, i.e. a bulge leads to a protrusion which is more likely to lead to herniation.

Healing / treatment:

The human spine is a resilient structure and for the most part, heals well, i.e. most minor disc herniations can heal over several weeks.

Medical intervention includes anti-inflammatory treatment and in some cases anaesthetic injection or even surgery.

Conservative treatments, i.e. Physiotherapy, Chiropractic and Osteopathic therapies, demonstrate efficacy in the management and prevention of low back pain associated with disc aberrations.

Symptoms:

The patient may experience pain, numbness, tingling etc. effecting lower back, buttocks, thigh, anal/genital region (via the perineal nerve). This may radiate to the foot and/or toe. Sciatica is often mis-used in referring to low back pain with concomitant lower limb pain. True sciatica involves the largest nerve in the body, the sciatic nerve. Other nerves that can be implicated include the femoral nerve [10].

General symptoms’ numbness, tingling, appearing throughout one or both legs and even feet, or even a burning feeling in the hips and legs.

A herniated disc may physically compress the nerve root exiting at the level below the disc.

Assessment:

It is important both the patient and practitioner work together to manage this condition. The patient needs to be encouraged to express their pain and how this impacts their day to day living. The patient should be encouraged to undertake self-care at home to assist mobility and function. The practitioner must continually assess the patient’s pain levels, and response to treatment, medical and Allied.  Regular neurological, orthopaedic and vascular examinations should be performed, e.g. checking the patient’s legs for colour, motion, temperature, and sensation changes. Monitor vital signs, and check for bowel sounds and abdominal distention. Educate the patient about treatment options, expect prognosis and home advice. These encourage general health initiatives including diet and weight management. Co-manage the patient with other health professionals so that a wider treatment process can be delivered.

In simple terms:

So, let’s break this down. A spinal disc is basically comprised of several fibrous ‘onion ring’ layers around a central material called the nucleus pulposis. The role of the disc is to act as a shock absorber. Age increases abnormal load bearing, injuries etc. may compound and lead to damage to the disk. This can happen over an extended period or acutely and produce an array of symptoms. Most commonly patients present with what I call uncomplicated back pain, i.e. an inflamed, bulging disc and associated structures including the nerve root possibly, with the possibility of a ‘papercut’ type tear in one of the ‘onion layers’. This can be a pain generator and cause the muscles to react by spasming and causing pain. This is not a slipped disc. Chiropractic manipulation/mobilisation, electrotherapy, soft-tissue etc. all help restore circulation and mobility to this area and reverse the altered joint mechanics. These people do not have referred pain.

The next stage is protrusion where more ‘onion rings’ have been disrupted. The nucleus pushes along a weak spot and produces a focal or broad bulge outside the normal parameter of the disc. This may impinge the nerve root. This person may have referred pain down the legs and be bent off to one side. Pain can still be variable. This is more like a slipped disc. A protrusion may still be amenable to chiropractic care.

The next stage is extrusion where the nucleus material has broken thru all the ‘onion rings’ and maybe sitting in the hole where the nerve roots exit the spine. This will produce referred pain down the legs, much more painful, and often requires pain meds and orthopedic assessments.

The next stage is sequestration, which not satisfactory. This certainly could be a medical emergency. You will be in severe pain, and certainly, this is beyond chiropractic care.

Your Chiropractor will start with plain film xrays. If you have referred pain, or more significant pain, not responding to treatment, he/she may refer you for CT scan via your GP. In some cases, an MRI may be indicated. These provide more detailed views of the disc.

Conclusion:

So a disc will slip relative the vertebrae above if it has torn in some way. Chiropractic care cannot reverse this slip. The putting your back, in phenomenon, relates to improving circulation and nerve supply to the area, thus facilitating scar tissue repair and helping reduce inflammation and therefore pain.

Orthopedic surgeons, for the most part, will always encourage conservative, Chiropractic/Physio care before considering any surgery.

The rule of thumb is if you can get yourself to the clinic then it is unlikely you have an acute disc problem. Chiropractic can certainly help your discs heal, and aid muscle rehabilitation, as well as aid prevention from something more serious, occurring.

For more information visit http://www.cranbournefamilychiro.com.au or call us on 59984554.

References:

[1] Ganguly A, Ganguly D, Evidence-Based Tropical Phytotherapeutic Treatment Protocol For Lumbar Slipped Disc: An Approach With Biochemical, Anatomical, Functional Disability and Radiological Parameters, Department of Research and Development, IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 17, Issue 9, Ver. 11 (September. 2018), PP 01-20 http://www.iosrjournals.org DOI: 10.9790/0853-1709110120 http://www.iosrjournals.org 1.

[2] Elshani B, Krasniqi S, Givligi R, Herniated lumbar disc and nursing care, Research & Innovation > Publications and Journals > IJBTE > Vol. 6 > Iss. 2 (2018).

[3] Alexander M. Dydyk; Ruben Ngnitewe Massa; Fassil B. Mesfin, Disc Herniation, Last Update: August 12, 2020, Copyright © 2020, StatPearls Publishing LLC, Bookshelf ID: NBK441822PMID: 28722852

[4] Park CH, Park ES, Lee SH, Lee KK, Kwon YK, Kang MS, Lee SY, Shin YH. Risk Factors for Early Recurrence After Transforaminal Endoscopic Lumbar Disc Decompression. Pain Physician. 2019 Mar;22(2):E133-E138. [PubMed]

[5] Huang JS, Fan BK, Liu JM. [Overview of risk factors for failed percutaneous transforaminal endoscopic discectomy in lumbar disc herniation]. Zhongguo Gu Shang. 2019 Feb 25;32(2):186-189. [PubMed]

[6] Fjeld OR, Grøvle L, Helgeland J, Småstuen MC, Solberg TK, Zwart JA, Grotle M. Complications, reoperation, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation. Bone Joint J. 2019 Apr;101-B(4):470-477. [PubMed]

[7] Tang C, Moser FG, Reveille J, Bruckel J, Weisman MH. Cauda Equina Syndrome in Ankylosing Spondylitis: Challenges in Diagnosis, Management, and Pathogenesis. J Rheumatol. 2019 Dec;46(12):1582-1588. [PubMed]

[8] Sharma SB, Kim JS. A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations. Neurospine. 2019 Mar;16(1):24-33. [PMC free article] [PubMed]

[9] Jordan J, Konstantinou K, O’Dowd J. Herniated lumbar disc. BMJ Clin Evid. 2009 Mar 26;2009 [PMC free article] [PubMed]

[10] Heo DH, Sharma S, Park CK. Endoscopic Treatment of Extraforaminal Entrapment of L5 Nerve Root (Far Out Syndrome) by Unilateral Biportal Endoscopic Approach: Technical Report and Preliminary Clinical Results. Neurospine. 2019 Mar;16(1):130-137. [PMC free article] [PubMed]