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I just need a review on this particular peer discussion. Please feel free to add any questions you my have.The intervertebral disc is composed of nucleus pulposus (jelly) which is surrounded by the annulus fibrosus (the donut) a thick outer layer.
A disc herniation is when the nucleus pulposes (the jelly) protrudes out of the annulus fibrosus. This occurs from a weakening or a tear in the annulus fibrosus either caused by acute trauma or repetitive microtrauma (faulty mechanics/posture or repetitive bending) that result in a failure of the tissue.
General Background:
Mechanisms for cute trauma: twisting while lifting a heavy or moderate load away from the midline of the body, lifting improperly (bending over and lifting moderate-heavy load without proper spinal stabilization), motor vehicle accident, injury, degeneration or a combination thereof (degeneration and an athletic injury or slipping/falling etc).
Early protrusion or a disc bulge (slight protrusion of the nucleus pulposes) does not always cause pain, pain is present when the nucleus pulposus truly herniates through the annulus pulposus and places pressure on adjacent structures such as the spinal cord (posterior herniation), or causes nerve root compression (posterior lateral herniation).
Herniations can occur at any level, however L4/L5, L5/S1 are the most common levels for disc herniation to occur.
Symptoms:
Centralized back pain
point tenderness over the spinal level at which the herniation has occurred
muscle spasm/tightness
sciatica and/or other nerve compression symptoms.
Red Flag Symptoms:
Bowel or bladder dysfunction; pain with intercourse
debilitating pain that affect ability to perform activities of daily living lasting longer than 12 weeks with NO improvement
gross motor loss; weakness, loss of sensation
If a nerve is compressed patients will c/o or experience radicular symptoms which is when they experience pain down the thigh, butt or along the foot. The particular pattern/area or location depends on which level of the lumbar was affected with the injury. In severe cases motor control for that specific nerve can also be affected (this is when someone may experience drop foot and they have trouble dorsiflexing their ankle during their gait cycle and may trip over their foot – that is considered a ‘red flag’ for the potential for surgical intervention).
Interventions:
Physical Therapy: Mechanics, mechanics, mechanics! Low back pain is one of the most debilitating injuries in the US! More often than not it can be addressed with out patient physical therapy addressing mechanics and being more mindful in the way in which we move, using modalities to help decrease pain and creating a movement plan to help the individual remain pain free and healthy moving forward.
The intervertebral discs are filled with fluid and the first hour of the day they will be at their ‘fullest’ so it is recommended to avoid flexing the spine esp with a load (for those of you who workout first thing in the morning – make sure you have an HOUR before you are deadlifting or performing other heavy lifts). Or those lifting your child out of their crib (do your best!). With the discs being “full” imagine flexing your spine and as you do that the vertebrae separate which is the perfect time for the jelly to say “I’m going shoot out!” with the right amount of wear and tear it only takes that one final episode! With repetitive stress the ligaments and soft tissue around the disc gets ‘worn’ down which ultimately leads to bending over to pick up a pencil and your “back goes out”.
Heathy movement habits & a healthy diet. Excess weight can increase pressure on the vertebrae which can increase symptoms. Incorporating or increasing healthy movement patterns can
Cortisone injections: Can help to manage pain. At times if the patient does not present with red flag symptoms or diagnostic testing to warrant surgery an injection can help them get “over the hump” and onto the next phase if the pain is long lasting and debilitating.
Surgery: This should in most cases be last case scenario UNLESS you are experiencing one of the RED flag symptoms above which can be an immediate indication for surgical intervention.
Herniated discs can have a huge impact on psychosocial aspect of injury and there is no ‘timeline’ like with a broken bone. Every individual heals different depending on the range/extent of the injury, how it is treated afterwards, and what caution and care is taken moving forward. LBP can range from 6 weeks to 9 years.
Ultimate Back Fitness and Performance – Stuart McGill
Examination of Musculoskeletal Injuries – Sandra Schultz, Peggy Houglum, David Perrin

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