Disc bulge the slipped disc
Introduction
Although people often refer to a disc bulge as a slipped disc, the disc doesn”t actually slip out of place. Rather, the terms bulge, protrusion or herniation means that the material at the centre of the disc has squeezed out of its normal space. This condition usually affects people between the ages of 30 and 40.
Anatomy
What parts of the spine are involved?
The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. It is the body”’’s main upright support. The section of the spine in the lower back is known as the lumbar spine.
Intervertebral discs separate the vertebrae. The discs are made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibres of a material called collagen. These fibres help the disc withstand tension and pressure.
A disc is made of two parts. The centre, called the nucleus, is spongy and is a gel like substance which can move. It provides most of the disc’’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.
Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity. They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.
Causes
Why do I have this problem?
Bulge occurs when the nucleus or the centre of the disc pushes backwards, and puts pressure at the back of the disc, causing it to bulge backward. Usually the bulge will cause pain the disc as it causes stress at the back of the disc to the surrounding layer of ligament. If the bulge is large it may put pressure on the nerves.
Protrusion occurs when the nucleus or the centre of the disc puts pressure backwards further than a bulge. The nucleus moves further backwards but not fully through the the back of the disc.
Herniation occurs when the nucleus in the centre of the disc pushes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge outward. Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc.
Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure.
However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc.
Vigorous, repetitive bending, twisting, and lifting or prolonged sitting can place abnormal pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus, leading to bulges or even herniation.
Bulges cause pain from a variety of sources. It can cause mechanical pain. This is pain that comes from the parts of the spine that move during activity, such as the discs and ligaments.
Pain from inflammation occurs when the nucleus squeezes through the annulus. The nucleus normally does not come in contact with the body’’s blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. A disc herniation may also put pressure against a spinal nerve. Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve. This is called neurogenic or radicular pain.
Symptoms
What does the condition feel like?
At first, patients may only experience a dull pain centred in the low back, pain that comes and goes over a period of a few years. This is mainly from small tears in the annulus. A larger disc bulge may cause immediate symptoms, with sharp pain that starts in one hip and shoots down part or all of the leg. Throbbing pain in the low back may be felt due to Inflammation produced by the body in response to the disc bulge.
A disc bulge can press against a spinal nerve, producing symptoms of nerve compression. Nerve pain follows known patterns in the lower limbs. It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes.
Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs. If this happens, a person’’s reflexes slow. The muscles controlled by the nerve weaken, and sensation in the skin where the nerve goes is impaired.
Rarely, symptoms involve changes in bowel and bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder.
The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn”t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Immediate surgery is required to remove pressure from the nerves.
What happens if I don’t fully fix my back? If a disc bulge is left untreated symptoms will continue to persist. If the disc is pressing on a nerve and treatment is delayed the nerve can take a lot longer to recover than if treatment was commenced promptly. This may result in a loss of strength in your legs or altered sensation such as pins and needles and numbness.
People with disc bulges also commonly alter their posture to help with the pain. Without treatment these postures can become habit and eventually lead to long term changes in posture. These changes increase the likelihood of other structures being damaged as the change in posture causes changes in pressure to other areas of the body that are not strong enough to handle the these changes
How long does it take to get fully better? Depending on the severity of the disc bulge recovery can range from a couple of weeks to several months. Receiving treatment promptly when symptoms appear will reduce the recovery period.
Ticket to freedom ~ your journey to full recovery
Your physio has been extensively trained by Precision Physio to give you a thorough assessment to determine exactly what is happening & prescribe the best management plan for your injured knee.
Precision Physio’s unique phase based rehab system makes your rehab easier for you to understand as it gives you a step-by-step program to ensure you achieve your best possible results. The most common phases, or steps, that you will go through during your rehab program are outlined for you on the next page. The order & timing of the phases will be individually tailored for you & so may vary form this list. Please feel free to ask your physio if you have any questions about the phases in your recovery plan.
Phase 1: optimise & control inflammation
Inflammation is the redness & swelling that occurs whenever you injure yourself. Our bodies need inflammation to start the normal healing process but we also need to control it. Inflammation makes chemicals which start up the defence & healing teams within our body. The defence teams destroy & remove damaged tissue which would normally slow the repair process. The healing teams than bring more of the healing chemicals which help your recovery.
Reducing the inflammation associated with a disc bulge can help to take away that initial ‘throbbing’ pain patients describe. By reducing inflammation your physiotherapist is able to work a lot more intensively on your back in restoring any lost movement you may have developed or continued discomfort you are having.
Techniques your physio may use to manage your inflammation include electrotherapy machines such as interferential and ultrasound and specific local massage. They may also suggest to you to see your GP to receive a prescription for some anti inflammatory medication
Phase 2: restore range of motion
Lumbar disc bulges result in the joints and vertebra in your back becoming less mobile leading to stiffness and restricted movement. Without correcting this joint stiffness a patient will not regain their full range of movement making a return to their normal lifestyle difficult. Without treating the less mobile joints the risk of re-injuring your back is increased as the body will have to compensate in other areas to avoid the stiff segments.
Techniques your physio may use to correct the joint stiffness and restricted range of motion include joint mobilizations, stretching, and soft tissue massage.
Phase 3: Re-educate movement patterns
Your body often changes the way it moves to compensate for the pain produced by the disc bulge. Although this can be helpful in the short term, in the long term it can be very detrimental. These ‘new’ postures can become habit and be difficult to change. This can lead to loading of other weaker structures not normally used to handling stress. This increases the risk of injury to other areas of your back and to other parts of your body.
By re-educating movement patterns your body is restored to its normal and most optimal alignment allowing for long term recovery.
In a lot of instances your ‘normal’ everyday movement patterns may have been a contributing factor to you sustaining the disc bulge. People who work at desks in front of computers all day tend to sit in flexed postures for long periods. This increases the stress on the lower back and gradually over time the stress can become too great and injury can occur. By helping you to change these postures the risk of re injury to your back is significantly reduced.
Techniques your physio may use to help you re-educate your movement patterns include core stability exercises, stretching and postural control exercises. Your physio will often use a mirror for these exercises to allow you to see how you should be performing the exercise and to allow you to make the necessary adjustments in your posture to do so
Phase 4: Re-Stabilise
This is one of the most important steps to ensuring full recovery from a lumbar disc bulge. Re-stabilising means retraining the muscles in your body that help to keep your spine strong and stable. Research has shown that your ‘core’ muscles are the first muscles to switch off when you get back pain. If these muscles switch off and are not properly retrained they lose their conditioning, become smaller and weaker and your chance of a full recovery is limited. By re-stabilising your spine you are able to move more efficiently and the risk of re-injury is significantly reduced.
Techniques your physio may use to help re-stabilise your spine include swiss ball exercises, deep tummy muscle exercises and for some people we recommend attending out physio ball classes to maximize your recovery from a lumbar disc bulge.
Phase 5: sports/ballistics & advanced strengthening
Once you are familiar with the exercises required to re-stabilise your spine your physio will then progress you to more advanced exercises specifically aimed at your activity or sport of interest. For muscle strengthening to be effective the muscles need to be strengthened in the specific way to how they will be used during your daily activities.
If you are a runner this means your physio will take you through a series of exercises aiming at activating your ‘core’ muscles while running. However, if you work at a desk all day in front of a computer your physio will take you through a variety of different exercises ensuring that you are able to correctly activate the correct core muscles while at your computer.
Phase 6: Check in sessions
This is the last phase of your journey to full recovery. Once your physiotherapist is satisfied that you have completely recovered from your disc bulge they will encourage you to return to your normal daily activities.
However, your physiotherapist may also advise you to occasionally return to see them periodically to recheck and update your home exercise program. This is an important step because it ensures you are continually challenging your body to become stronger with new and more advanced exercises