There are lots of scary terms associated with disc pathology, from slipped discs to disc prolapses. All of which can make you panic unless you understand what the pathology is, why it occurs and most importantly, what to do about it!
Disc anatomy may seem complex but can be easily compared to something as simple as a liquorice allsort. Discs have an outer portion of ringed fibres, with a soft jelly-like nucleus at the centre. A disc herniation occurs when some of the fibres of the outer ring (the black liquorice) of the disc are disrupted and consequently, the material of the nucleus (the jelly) leaks into this disrupted area.
Sometimes the nucleus may move only a small amount and stay within the disc, or sometimes it may extend through the fibres and begin to irritate the nerves adjacent to the disc. Both small bulges and large leaking of the nuclear material can irritate a nerve, as can the inflammation that occurs as a result of the disruption. If this affects the lower fibres of the spine, it is often referred to as sciatica. Sometimes you hear people refer to any pain in the leg associated with low back pain like sciatica, but this is not truly accurate. Other structures in the low back can cause pain to radiate down the leg such as the disc itself, muscle and the facet joints.
Importantly, research has shown that the extent of your symptoms doesn’t necessarily correlate with the degree of herniation within a disc. And more importantly, the herniation does not need to reduce in size on a scan for your symptoms to resolve. A great deal of research into low back pain has demonstrated that lots of people are wandering around with disc bulges and other “spinal pathology” that would be evident on a scan, but they are completely pain-free. It is one reason why X‑rays and scans are rarely the first course of action if you present to see a doctor or other clinician with back pain.
The following diagram shows the different types of disc herniation that you may hear people talk about:
It is impossible to tell from a clinical examination, what type of disc pathology is present, especially because the type of herniation doesn’t correlate to a level of pain or the presence of nerve irritation. Remember — 10 – 81% of individuals with no pain, will have some kind of disc pathology. The key thing to treatment is to treat the person, not the scan or the pathology.
As indicated above, symptoms are very variable. Disc pathology alone can cause pain in the back as well as referred pain into the limb. This type of pain is usually a dull, aching, toothache kind of pain. If nerve tissue is irritated, the pain is usually more severe, sharp and burning. It is often difficult for people with nerve pain to sleep due to the pain. Nerve irritation can sometimes result in pins and needles/tingling or numbness, and occasionally in sensations of weakness. Very rarely, if the disc pathology occurs very low down in the back, it can irritate the nerves that supply your bowel and bladder. This is called Cauda Equina Syndrome and it is a very serious condition that requires immediate medical attention. Click this link to read more about it elsewhere together with a list of possible symptoms.
The truth is – we don’t really know. As we have said – lots of people without back pain have disc pathology, so we need to be careful in saying you did this activity, you have pain and your spine shows evidence of disc pathology, therefore that is the cause. The pathology could have been there for a long time before the activity. In most cases, back pain is the result of a combination of factors that are unique to each individual. Research has shown that factors such as poor general fitness, fatigue, stress and sudden changes in activity level s (increases or decreases) are associated with back pain developing. It’s usually impossible to identify one precipitating factor – it’s more like a “perfect storm” – a combination of small, minor factors (each individually of no consequence) but when added together result in pain.
The most important thing in treating back pain associated with disc pathology is to understand the information above about the pathology and its relationship to back pain. If you are reading this and have back pain, you should take this information to your health care professional, along with any questions you have, so that you can learn what is important in managing your pain and getting back to full function as quickly as possible.
Avoiding activity and lying/sitting down for long periods of time will only make matters worse. You should try and stay as active and mobile as possible, even if this requires medication for pain relief (Paracetamol, Aspirin, Ibuprofen) for a short period of time. Many people try to avoid pain relief, but it can be very beneficial in the short term to help you stay active and avoid a cycle of ongoing, constant pain. Always get advice on taking over-the-counter medication from a suitably qualified healthcare professional such as your GP, Practice Nurse, Pharmacist or Physiotherapist.
In the short term focus your active exercise on walking, cycling and gentle swimming.
Manual therapy can be beneficial for the management of symptoms, however, research has shown that manual therapy alone is very unlikely to resolve all symptoms or have a long-lasting effect. Instead, we advise manual therapy in the initial stages alongside an individualised structured exercise program, designed just for you and prescribed by a qualified clinician. An effective programme should address specific problems you are having – including issues with flexibility. It is not just “Core Stability” that is important, and for many people, too much “core” work, can make them worse – a bit like clenching your teeth too hard, for too long. Our bodies are made to move – and this is what your clinician should be working with you to achieve – effortless, pain-free movement.
Finally, there is some research to support the use of steroid injections as part of the management of the symptoms of disc pathology, but this should only be considered if your pain has not improved with other elements of treatment. It is well documented that they should not be considered as providing a solution to pain, but in providing a window of opportunity to allow you to exercise effectively in order to achieve long-term relief. Some patients may also consider surgery as a treatment, however, 90% of herniated discs will resolve without surgical management, a very comforting figure if you are diagnosed with disc pathology. Surgery should only be considered in cases of Cauda Equina Syndrome or severe, unremitting symptoms with worsening neurological symptoms such as weakness.
To conclude, disc pathology can be a painful but completely treatable pathology. Ensuring you partake in regular exercise and knowing how to manage early symptoms, using the information explained above, will reduce the risk of more serious pain and dysfunction developing.
If you’re suffering from back pain, book an appointment to see one of out physiotherapist today.