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Lumbar Disc Herniation

It is common for people to wonder if they have a herniated disc in their lower back when they feel pain radiate down the leg.  There are several differential diagnoses that must first be ruled out before that conclusion is made.  The only way to confirm a herniation diagnosis is with an MRI but a good physical and neurologic assessment is often enough to determine the cause of lower back pain that refers into the leg.  If you are wondering if you are suffering from a herniated disc in the lumbar spine and you want to know what your options are, this posting is for you.

Presentation
  • Sudden onset of lower back pain with severe pain down the leg possibly beyond the knee.
  • The leg pain may be more severe than the back pain.
  • Pain may result from heavy lifting, twisting or repetitive stress trauma.
  • The leg pain is described as “electrical”, “sharp” or “shooting.”  The pain follows a dermatomal pattern determined by the spinal level of the herniation as pictured below.

  •  The leg pain is worsened by increases in intra-disc pressure:  coughing, sneezing, weight bearing, and positional changes that involve forward flexion of the low back and at the hip.

Additional findings:  Dermatomal numbness/ decreased sensation, weakness, decreased reflexes.

 Etiology
  • Age 25-45 this is when the nucleus is most hydrated
  • male >female 3:2
  • Prevalence:  1-3% lower back pain cases
  • 95% of lumbar herniations occur at the L4-5, L5-S1 levels



Differential Diagnosis

  • Piriformis/sciatica-  Sciatica feels like a disc herniation but it is not.  Sciatica is when the sciatic nerve is entrapped distally from the spine, typically by a muscle such as the piriformis.  This still presents with pain down the back of the leg to the foot and is best treated with chiropractic manipulation of the sacrum and soft tissue work on the piriformis muscle.
  • Myofascial Trigger Point- A trigger point is a small region within a muscle that refers pain distally.  They are easily treated with trigger point therapy involving light repeated pressure into the source muscle.  The source of this referred pain can be quite a distance from where it manifests as is illustrated in the trigger point map pictured below.  Acupuncture also has very effective treatment strategies for trigger points.
  • Acute hamstring spasm or strain must also be ruled out as a possible source of sharp pain down the back of the leg.
 Risk Factors
Biomechanical and lifestyle factors that expose you to increased risk of lumbar disc heritaion include:
  • Lower Cross Syndrome:  A postural shift toward anterior pelvic tilt caused by imbalanced forces across the hips as pictured below.  Weak abdominals, a tight lower back, and tight, weak hamstrings and glutes result in excess pressure on the posterior disc fibers.
  • Lack of exercise/ poor general health and nutrition.  This is why I promote vigorous physical activity with my patient population.  I encourage my patients to learn how to safely move very heavy weights and to practice those motions regularly.
Treatment Options

Conservative:
Cauda Equina Syndrome presents with saddle parasthesia and urinary retention.  It is an emergency situation.  Care of all presentations except Cauda Equina should begin with conservative care.

Conservative care of a disc herniation is the non-surgical and drug free route.  Except in the case of Cauda Equina Syndrome, this is where all initial care should begin.  It involves mobilizing the vertebrae to accomodate the return of the disc material out of the intervertebral foramen.  In chiropractic, several techniques are used including Flexion/Extension, The McKenzie Protocol and Chiropractic manipulative therapy.  Yes, it is safe to adjust a spine with a disc herniation.  It is infact the standard of care. [2] [4]  An estimate of the risk of spinal manipulation causing a clinically worsened disc herniation in a patient presenting with lumbar disc herniation is calculated from published data to be less than 1 in 3.7 million.  [1]  Alternative conservative care modalities include Massage, Acupuncture, and physical therapy.

Surgical:

This is the best option with acute Cauda Equina Syndrome, and is the last option when progressive neurological deficiencies are present during the course of conservative management.  That means you are doing the exercises and being adjusted but you continue to digress measurably with loss of muscle strength, tone, and reflexes.  Surgery is also the preferred treatment option in cases of sequestration of the disc material  into the spinal canal as pictured above.  This is a last resort in care because of recent reviews of the literature that reveal even in successful spinal surgeries, the benefits are short-lived and are indistinguishable from conservative outcomes on an 8 year time line. [3]   I nearly placed  photo of a lumbar surgery in progress here but after the achilles shot last week, I thought that might be too much.  For the curious in the group, click here for link to a short youtube video.  When going through these videos I found the most interesting part to be the comments left by viewers.  They all have had the procedures themselves and they are a solid random sampling of outcomes that reflect a hit and miss level of relief.

Summary: 

Recent MRI studies of asymptomatic populations find that as many as 52% of asymptomatic people have lumbar disc bulges and hernitations! [5]  The difference between a benign asymptomatic lesion and a debilitating one is likely your personal biomechanics and how you use your spine day to day.  Because of this, the best way to treat a symptomatic disc herniation is to avoid one.  An assessment of the biomechanical forces that your lower back is exposed to both statically and with your lifting technique will have you on the right path.  If it is too late for that and you already present with symptoms, beginning a course of conservative care now will typically result in 50% improvement in symptoms within the first 3 weeks of initiating care.

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