A diagram showing a disc bulge or herniation

Recovering from a Lumbar Disc Injury

Recovering from a Lumbar Disc Injury

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.

When to call a doctor

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.

Disc bulge and herniationWith 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

  • Rest. Rest. Rest some more. Get horizontal as frequently as you can during the day. Take time off work. Avoid sitting as much as possible and if you do sit never slouch on the couch. Lie down or stand leaning back against the wall if you are tired.
  • Avoid lifting anything over 2 – 5 kg and avoid any thing else that aggravates the pain.
  • Don’t stiffen against the pain. Try to keep moving and relax your muscles. If possible get up and walk around regularly but lie down again if pain starts to worsen.
  • Learn some gentle exercises that you can do at home to maintain your range of movement and activate the spinal support muscles. Get professional help from an experienced Physiotherapist for this.
  • See your doctor for a neurological examination and medication to assist with managing the pain. Too little pain medication may result in severe muscle spasm and create a vicious cycle of pain and tension. Too much analgesia and you may unknowingly move in a way that aggravates the problem.
  • Try other pain relieving measures such as a heat packs, cold packs or a TENS machine.
  • If you absolutely have to sit, try various back supports to improve your posture and spinal stability for example an individually moulded back brace can be fitted for you and worn a few hours a day to improve spinal stability and comfort while you are on your feet. A lumbar support cushion can often help when you have to sit.

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

  • Gradually get moving. Walking can be a helpful exercise for some people, others find it aggravating. Pace yourself. Listen to your body’s messages. Try walking in warm, waist-deep water, but remember anything can aggravate your symptoms if you over-do it.
  • Restrict sitting to short periods of time if it aggravates your pain and always use adequate lumbar support, such as a BodyBolster or contoured lumbar cushion,  especially when driving or sitting at a computer. (Free2Move sell both.)
  • Have a Physiotherapy assessment and get an individual exercise programme specific to your individual situation. Remember that the wrong exercises or exercising too soon can make you worse instead of better.
  •  Get your Physiotherapist to show you how to test the safety of any exercise. Learn which type of exercises relieve your pain – for example spine neutral or extension based exercises are usually best for lumbar disc pain.
  • Be careful but not overly cautious (or stiff) when bending and lifting. Don’t lift anything over 5 to 10 kg. Get your Physiotherapist to check your lifting and bending techniques.
  • Learn to let go of the muscle spasm (Feldenkrais classes are amazing for this – more effective than a massage and you can do it for yourself).
  • Improve postural awareness (Feldenkrais and Clinical Pilates)
  • If you aggravate things go back to the acute stage.
  • Have patience. A moderate disc bulge will take around 6 weeks to get better but only IF you do the right thing, but may never heal if you keep aggravating it.
  • See your doctor if symptoms don’t improve.

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.

Jodie and Feldenkrais 1

The major tasks in recovering your normal muscle function and posture are:

  1. Correcting imbalances which occur when one muscle group becomes habitually tight and it’s opposing group switches off or becomes significantly weakened.
  2. Sensing ‘neutral’ postural alignment in order to correct your posture.
  3. Learning safe ways to move and do everyday things so that you won’t re-injure yourself, for example learn to improve the way you roll over, get up from lying or sitting, bend, reach and lift so that there is the least possible strain on your back.
  4. Read More about Chronic Pain

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.

Feel free to email me or come for an individual assessment if you would like to discuss your situation.

Copyright Jodie Krantz February 2014