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Lumbar Radiculopathy/ Vertebral Disc Herniation

Vertebral herniation is a common phenomenon amongst most of the general population. Unlike the common belief, it is not attributed to sportsmen, athletes or the elderly. It can occur to any person of any age. None the less, not every “bulging disc” is actually symptomatic or a cause of pain. In this article, the lumbar (low back) region will be given as example.

General Anatomy:

Between each vertebra we can find the intervertebral disc. From neck to pelvis, the disc is comprised of a drop of gelatin like substance called the nucleus polposus surrounded by a matrix of ligaments (the Annulus fibrosis), which encapsulate it into 1 unit.

The purpose of the disc is to function a shock-absorbing unit for the spine and allow the spine to move in a both stable and flexible manner.

Behind the disc, the spinal nerve roots emerge from the spinal cord and extend into the peripheral nerves that innervate the muscles and sensory functions. The nerves function as a tube for transferring data to and from the brain to the tissues of the body.

The disc is supported on the anterior (front) part by a very dense ligament that supports most of the anterior surface of the spine, In addition to another ligament, more flexible in nature. Because the anterior part is so supported, it is very rare to see an anterior herniation.

On the posterior (back) side of the disc, passes another ligament. This ligament is thinner and weaker in comparison to the anterior and doesn’t support most of the posterior surface of the vertebrae. This explains why most herniations occur in the back and side regions of the spine. It can be easily understood due to the fact that there is an increased ability of the body to flex forward than extend backwards. After all, most of our daily functions occur in front of us. We are also situated in a flexed position 24/7, 9 months before birth.

Injury mechanism:

When the pressure arises inside the nucleus (the reason will be entailed later in the article), it starts to press against the annulus. The annulus starts to stretch until it starts to bulge out or even reach a critical point in which it starts to tear. In that location starts an inflammatory process that includes swelling and increased vascular reactions. This swelling contribute to the pressure on the pain receptors in the annulus and it can even touch or press on the nerve root itself. The annulus itself is very rich in pain sensors which contribute to the sharp pain feeling.

There are 3 levels (differing from one school to the other) of herniation:

  1. protrusion: in which the annulus just starts to bulge out and stretch beyond its capabilities.
  2. Prolapse: in which the annulus starts to tear.
  3. Sequester: in which the annulus is completely torn and the nucleus “pours” out into the spinal canal.

Symptoms associated with this injury:

  1. Sharp and local pain in the area, Increases with movement especially forwards or to the other side of the injury but not necessarily. Backwards extension and rotations might also aggravate the symptoms especially in the acute phase. Pain might also arise during static postures especially in prolonged sitting and lying on the back or the affected side.
  2. Sensations of pins and needles, inner pressure, deep discomfort, tingling or even lack of sensation and weakness in the limbs. The deeper the herniation is, the more the symptoms will show in motor deficits such as weakness, movement instability, incontinence.
  3. Isolated pain sensations in joints or muscles along the limbs (could be 1 limb or both) during movement. Pain in the elbow region for example during a hand shake, heel pain while climibing stairs, shoulder pain while putting on a bra etc. might show a localized character but could be the result of a nerve root compression that innervates that specific area.

Why does the disc herniates?

  1. Faulty posture during sitting or standing: during a slouched posture in sitting, the back arches forward which causes an increase in pressure on the front part of the disc. During which the nucleus inside the disc is being pushed backwards against the annulus and the injury starts. Just as when we are pressing on cookie doe on one side, it will bulge to the other side. In the neck region during a slouched posture, the neck extends backwards while the head move forwards. This causes a narrowing of the space between the vertebras where the nerve root is situated.
    The posture can be influenced by an improper work environment, unsupportive chairs and an imbalance between table and chair heights or levels.
  2. Asymmetry of the pelvis joints during movement: The spinal column actually “sits” on and in between the pelvic joints. These joints comprise of the pelvic bones and the bottom of the spine (the sacrum). If the movement in these joints is not symmetrical, an unbalanced pressure will be placed on the low back vertebras, discs and other structures and give rise to conditions, optimal for herniation. Some schools of thought claim that there is no movement that takes place in the SI joints. Never the less, all schools of thought agree that load from the lower limbs to the upper body and vice versa is passing through this region and any imbalance in this region will unnecessarily over load the most adjacent structures as the spine and discs.
  3. Degeneration or immobility in the vertebral joints: during movement the vertebras glide on top of each other through joints situated at their sides. Their ability to glide enables the pressure inside the disc to adapt according to the movement. This prevents a rise in pressure inside the disc and enables a broader and wider range of motion while maintaining stability. When these joints degenerate due to inactivity, years of faulty posture that loads them in an unbalanced way, wear and tear due to aging degenerations, the following can occur: during movement (e.g flexing the trunk forward) these joints will enable movement for only a part of the way, enable the disc to stretch on its back part. When the movement will cease at a certain level due to a limitations in the spinal joins, the trunk will continue to flex forward but through an increase in the pressure of the disc. For example, if I’ll inflate a balloon but border its margins, the pressure inside the balloon will increase earlier and it will explode much sooner in
    comparison to if its margins would have been left free.
  4. Lack of muscular control: even though the disc allows for both spinal mobility and stability, there is a vast system of muscles around the back, stomach, hips and pelvis that maintain an active stability of the spinal segments, pelvic bones, joints etc. Never the less, strength in these muscles is not enough. The ability of the nervous system to control the activity and timing of contraction of these muscles is just as important. There’s a vast system of sensors situated in muscles, tendons, joint capsules and even the skin that sends signals associated with stretch, tension, muscle contraction respectively to the brain. The brain processes all of these signals and develops an image of how the movement is carried out. If this
    system is untrained or neglected, the movement image in the brain is presented improperly or incorrect. Therefore, over use of muscles, unbalanced contractions can occur and lead to overload on the disc and other spinal structures.

Treatment

  1. At first rest and unloading the back area is crucial in order to allow the body to react to the stimuli, allow the swelling to subside and prevent further irritation. This doesn’t mean necessarily avoidance of movement or lying in bed all day. Movement is necessary but in a controlled way
    and not into pain.
  2. Controlling the inflammatory process through medication, electrotherapy, heat or cold therapy, taping and isolated movement by a qualified physiotherapist.
  3. Evaluation of the movement of the spine, lower limbs and pelvis.
    gym6
  4. Manual therapy by the physiotherapist that includes segmental movement mobilization of limited structures, connective tissue massages and stretches. These types of therapy will eventually assist to increase the space between the vertebras where the spinal root passes and decrease the load on its blood vessels. These are very thin blood vessels and even a small change in pressure can help the nerve to regenerate. Nerve dynamics will assist to mobilize the nerve itself in that space and help to relieve it and increase its connectivity.
    low back pain
  5. Strengthening of the active neuro-muscular system that supports the active stability of the spine through specific exercises.
    low back pain 3
  6. Postural learning and prevention.
  7. Taping- specialized sticky bandages that unload certain structures, help in motor control, reduce pain and improve blood and lymph flow.
    low back pain 2
  8. In certain conditions in which none of the above help or in conditions where incontinence or severe motor loss is indicated, surgical intervention is necessary in removing a part of the disc that presses on the nerve root. Other techniques might include fixation of 2 segments together and others. Surgical techniques have improved dramatically in the past years and their results.

In conclusion

disc herniations can occur to anyone at any age. None the less, proper training, strengthening, range of motion exercises, motor control and stretches can help dramatically in the prevention of this phenomena.

***This article mentions several methods of evaluation and treatment. These are merely guidelines. They are not an independent treatment program nor intended to replace a thorough evaluation and treatment program executed by a certified physiotherapist. Its advised to undergo such evaluation and treatment by a certified physiotherapist if such injury occurs and act upon their professional judgement call***