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A disc bulge or prolapse can occur in the neck, lower or middle back. The lowest lumbar discs (L4/5 and L5/S1) take the most weight and often form a ‘hinge point’ for movement of the trunk. By far the majority of lumbar disc injuries occur at these two levels.
Basic Anatomy and Pathology
To understand a disc bulge or herniation first requires a basic understanding of the anatomy. The spine consists of a series of 24 vertebrae, plus the sacrum and tail bone at the base of the spine. Each inter-vertebral discs sits between a pair of vertebrae, acting as a shock absorber and allowing the spine to bend. Each disc is a mini-hydraulic system, with tough, concentric fibrous layers on the outside (the annulus fibrosus) and soft mobile material in the centre (the nucleus pulposis).
A disc bulge occurs when a weakness in the outer wall (the annulus fibrosis) allows the disc to change shape. The material on the inside (the nucleus pulposis) bulges outwards deforming the outer wall, which may put pressure on sensitive surrounding structures including the nerve roots. This is a common and less severe form of disc injury.
A disc herniation (also called a disc prolapse) occurs when pressure on the disc causes the softer nucleus material to crack the outer wall of the disc and leak out.
Most commonly the material bulges towards the back of the body, either centrally or to one side, where it may put pressure on sensitive structures such as ligaments and spinal nerves. Local swelling and inflammation may increase this pressure. Irritation of the nerve roots in the lower back may cause sciatica – pain anywhere along the course of the sciatic nerve, which passes through the buttock, down the back of the thigh, where it divides in two branches which go down the lower leg to the foot. (Not all leg pain associated with lower back problems are caused by sciatica however.)
Symptoms
With a minor lumbar disc bulge or herniation, pain will be localised to the lower back, possibly radiating to the buttock or thigh at times. The pain is usually worsened by prolonged sitting, bending, or simply staying in any one position for too long. In more severe cases, pain may extend down the leg on one or both sides, or alternate sides, sometimes as far as the foot. The pain may be constant or may come and go.
If the disc impinges on a nerve root, there maybe be neurological signs such as numbness, pins and needles or loss of power in parts of one or both legs. People with significant neurological symptoms may have to consider surgery, however surgery poses significant risks and in most cases it is worth trying less invasive approaches first.
Things to consider
Please bear in mind two things. Some people have a disc bulge on MRI or CT scan but no pain at all. Also pain often comes from more than one structure. You could have an un-diagnosed problem in addition to the disc bulge, such as a jammed facet joint or sacro-iliac joint or soft tissue pain from muscles and ligaments, which cannot be imaged well with CT scanning. Inflammation, instability or minor mal-alignment may not show up on any scan. Just because a disc problem shows up on your scan does not prove that this is what is causing your pain.
Can a disc heal?
Now the important question about the disc. Can it heal? YES. A major prolapse or herniation may not heal by itself and surgery may be advisable in some cases, but potentially a bulge and small to moderate sized prolapses can be healed by the body’s own repair processes in time. How long? That depends on how severe and how unstable it is, your age and most importantly how much stress you put on it, which is the part you can control. It also depends on the state of your spinal and abdominal muscles, as weakness or imbalances in these may be part of what caused the problem in the first place.
With a disc bulge, the walls of the disc are still intact, and healing time is shorter, though in some cases it can still take months. With a disc herniation (prolapse) it can take many months or even years to resolve.
Once you injure your disc, it will be unstable for a period of time (months or years for a severe prolapse). This means that the disc will bulge a lot more than usual when you are weight-bearing (eg standing, sitting, bending, lifting) and typically gets worse as the day goes on. An unstable disc is more likely in a young or middle aged person because as you get older the disc dehydrates and the nucleus becomes more rigid – stiffer but more stable. Young people may heal quicker after a disc injury due to tissue repair processes.
How to recover in the shortest possible time
Acute stage: severe, disabling, constant pain
The single biggest factor in disc healing, in my opinion, is NOT STRESSING IT. You want to maintain your physical fitness, range of movement and strength to the best of your ability without aggravating the pain. Aggravation of the pain may mean that you have pushed the wall of the disc out further again, worsening the bulge.
Importantly, no practitioner can ‘put a disc back in’ though some claim to. The temporary relief of pain associated with adjustment / manipulation may be due to the release of neuro-chemicals – your body’s own pain relieving substances. Massage and physio can relieve other aspects of the pain such as joint stiffness and muscle spasm, but this is also temporary. There is also a high risk of aggravating a disc injury with spinal adjustment, manipulation or even massage.
Be very cautious with any exercises. You have to start with very minimal subtle exercises and progress vary carefully under professional guidance and listening to your own body.
Sub-acute stage: moderate pain which comes and goes
What if it becomes chronic?
A ‘chronic’ condition is one that persists over time without improving, usually more than 3 months. Once a condition becomes chronic it is harder to reverse, because the body adapts to it. Changes occur in the way your brain interprets pain messages. Muscle imbalances and compensation patterns often develop. These may have been part of the initial cause of the injury, or may have developed as part of your body’s response to the injury. Either way once this occurs the disc injury and / or the pain associated with it become the body’s ‘normal’ state and you have to find a way to break the cycle.
Recent research shows that people who develop low back pain have difficulty activating the deep abdominal and pelvic muscles which are a part of the normal stabilising mechanisms of the lower back. The muscles may have become weak, difficult to activate, or there may be a delay in their activation, so that they are too slow to switch on. You may go to lift something for example and at the critical moment, if the muscles have not engaged to stabilise your lower back, the result is strain and further injury.
Muscle spasm or tightness is also extremely common in people who have chronic lower back. Immediately after your injury, the muscle spasm actually helps to protect you, It restricts your movement and helps avoid further damage. Long term though, the muscle spasm becomes a source of considerable pain and inhibits normal movement. Here’s an analogy: If you break a leg and don’t get it set in plaster (or surgically fixed) the bone might not ever heal. But if you left the plaster on for the rest for the rest of your life, the plaster would become the problem, rather than the solution to your problem.
Surgery may be less likely to be effective once pain becomes chronic, because surgery can help correct the structural problems but the defective way that the muscles are working can only be corrected by skillful muscle re-education. If you do end up having surgery it is absolutely essential to participate in a specific muscle and posture re-training programme that is customised to your particular strengths and weaknesses. It is very hard to work this out yourself, even if you are a therapist or movement teacher, because you will almost certainly have ‘blind spots’, things you are not aware of about your own habitual muscle use.
The major tasks in recovering your normal muscle function and posture are:
Good luck and remember it will take time to recover. Make sure you get professional help so that you are sure you are on track, but also it’s critical that you learn to listen to your own body signals. For this I have not discovered anything better than the Feldenkrais Method.
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Copyright Jodie Krantz February 2020
