Disc bulges, or herniations, come in a variety of presentations. They usually are limited to the lower lumbar spine (L3/4 to L5/S1) and the neck (C4/5-C7/T1). In taking the medical history of patients suffering from disc bulges, there is usually a history of a sedentary office job that requires sitting long hours; a previous injury like a sports, work, or car accident injury; and in rare cases, no significant event or habit that could explain how the disc bulge occurred. In fact, there are studies that indicate that degenerative disc disease, which can include varying degrees of disc bulging, can be hereditary.
A common theoretical model for degenerative discs goes like this: something happens that causes the disc to bear excessive weight, which over time forces fluid out of the disc causing it to dessicate. The outer fibers responsible for keeping the disc intact and the nucleus in place weaken, allowing the center nucleus to bulge outwards. Chiropractors often attribute this scenario to subtle misalignments in the vertebrae caused by minor trauma, prolonged sitting and insufficient support from the abdominal muscles and lumbar muscles. Normally the disc should support 80% of the weight above it and the facet joints (the smaller joints behind the disc) about 20%. But if a physical event changes the orientation of the vertebra, it can force the disc to support 90-100% of the weight, accelerating its demise.
Other models reference calcification of thevertebral end plates,the surfaces of the vertebrae above and below the disc, which then prohibits capillaries from feeding nutrients to the disc causing it to die. Bone calcifies in response to trauma; vertebral end plates can sustain “micro-compression” injuries from activities that place a heavy, axial load (perpendicular) to the disc. Examples include basketball, gymnastics, running, and parachuting.
An acute herniated disc can be extremely debilitating, as it tends to last a lot longer than a typical sprain/strain injury. It hurts, limits movement, can make sleep difficult and restricts you from work and physical activity. If it presses on a nerve root it can send shooting pains down the buttock and leg and cause numbness and weakness. The general recommendation for most cases of non-emergency disc herniations is to manage the pain using physiotherapy (ice, heat, muscle stim, laser), do physical therapy including stretching and strengthening exercises and wait for the disc bulge to self-resolve in 2-3 weeks. Once it heals and the inflammation goes down, the pain usually goes down as well.
If your disc herniation is pressing on a nerve root, the disc may shrink as it heals, removing pressure from the nerve. This is the best scenario obviously, as you avoid surgery and get your life back. At this point, it is prudent to avoid activity that risks re-injury (heavy lifting while turning torso) and do everything you can to strengthen your core muscles and spinal muscles to guard against re-injury. Functional exercises should be emphasized, for this purpose.
The thing that can dramatically increase the chances of full recovery without surgery is healing your insides– reduce systemic inflammation by getting down to a healthy weight and maintaining it; stop smoking, avoid alcohol as best you can, reduce stress, reduce insulin levels, maintain normal blood glucose levels, ensure that your gut micro flora is in balance, and get adequate sleep every day. Eat healthy, decrease your portions, and drink enough water to stay hydrated throughout the day. Exercise consistently, 20-40 minutes each time. This is what a healthy lifestyle routine is made of.
People who are in pain usually are concerned about knocking down the pain first, and ignore the health of the rest of their body. Remember, your entire body is essentially a colony of specialized cells that are interconnected via the bloodstream, nerves, and hormones. When one area is injured, the rest can come to its aid.
If you suffer from disc herniations, joint pain or other musculoskeletal form of pain and are overweight, pay more attention to getting yourself healthy inside; it’s the often ignored self-help method to treat pain.
For many individuals searching the internet for solutions to their lower back pain, Laser Spine Institute, or LSI is a familiar name. This is a network of physician-owned spinal surgery centers that rely heavily on Google and other internet search engines to obtain their clients. Their chosen niche is minimally invasive laser surgery, where the physician makes a tiny incision in the patients back and inserts a fiber optic laser and tiny camera to ablate, or burn off nerve endings around an offending spinal disc. Then, they may burn off part of the disc that is compressing nerve tissue. Through their marketing, LSI suggests that patients can be back on their feet within hours of the surgery.
However, the center is attracting a lot of attention in the malpractice arena. And, respected spinal surgeons not affiliated with LSI say that such a methodology is already available through standard medical care for spinal disc problems and cost much less; although instead of lasers, radiofrequency devices are used.
Laser Spine and its competitors, part of a boom in outpatient clinics operated by entrepreneurial physicians, sell a high-tech version of procedures that have been around for years — despite a lack of independent research to show that their variations lead to better outcomes. The company commands higher prices than laser-less rivals, driving up the cost of health care. Its number of malpractice claims per 1,000 surgeries is several times the rate for all U.S. outpatient surgery centers, based on insurance industry data.
…There’s little government oversight regarding which doctors can do spine surgery — all they need is a medical license, whether their training is in orthopedics, foot surgery or pediatrics…
…Doctor-investors may lower their standards for deciding when to operate, according to researchers from the University of Michigan in a study in the journal Health Affairs last year. Looking at five common procedures at Florida surgery centers, they found that once doctors became investors, the number of surgeries they performed increased by 87 percent.
So, if you are considering spinal surgery and run across LSI, make sure to do your due diligence. Being in acute pain can make one vulnerable to lofty marketing, as there is an urgency to make a fast decision. Based on this article, it seems that there are three main problems with Laser Spine Institute:
1. There is a conflict of interest, as some doctors are investors in the parent company. Thus, there is an incentive for performing unnecessary procedures.
2. There is little if any respected research that suggests that laser surgery is superior to traditional spinal surgery methods.
3. The centers use a high volume model and rely heavily on advertising instead of professional referral. Not a good indicator for quality of service.
The short answer to the first question is “yes” if the bulge is not severe and the body still has in place the mechanisms to keep the disc living and healthy (see below).
The other answer to the first question is “no” if the disc bulge is the result of breakdown of the nutrient-delivery mechanism to the disc. If this is the case, it is a matter of time before the disc totally degenerates. Physical therapy, chiropractic, spinal decompression and exercises can slow it down, but one cannot do these things indefinitely and often enough to stop the progression.
It’s important to know that your spinal discs are mostly avascular; meaning, don’t have a direct blood supply. Discs get their nutrients (water, oxygen, glucose, minerals, vitamins) via slow absorption from the capillaries directly underneath the vertebral end plates. At the end of the day, your discs flatten from the effects of gravity. As you sleep, they soak up fluids and expand, so that by the time you wake up in the morning you are at least 5 mm taller than when you first went to bed. This is called the diurnal cycle of fluid movement in and out of the disc and is the major means of nutrient delivery.
At the center of the disc is the nucleus, which has tiny cells that make the proteoglycan molecules responsible for attracting and holding onto water. This maintains a hydrostatic pressure that allows the disc to bear about 80% of the weight applied to its spinal level. These cells, similar to chondrocytes that make collagen in the joints, are the most active when the pressure in the disc is about 3 atmospheres. If the pressure is higher (obese individuals, those who carry heavy weight frequently at work) or lower, the cells make less of these molecules, putting the disc at greater risk of drying out. Injuries to the internal part of the disc or vertebral bodies can increase the volume of the nucleus, drastically reducing its hydrostatic pressure and slowing down proteoglycan synthesis. This is one of the pathways of degenerative disc disease, or DDD as the posterior (facet) joints, which are not designed for bearing much weight take on the responsibility of the disc and quickly wear down, forming the familiar osteophytes (bone spurs) seen on X-ray and MRI studies.
Here are the basic risk factors for developing DDD/ bulging discs:
1) History of Structural Damage to the Disc or Vertebra
Single event trauma to the spine resulting in damage to the vertebral end plates . An example would be a parachuter landing hard on the ground on his feet. This can cause a small injury, or even a significant compression fracture to the bony end plates– the surfaces to which the disc attaches. This is bad news, because nutrients to the disc (blood, oxygen, glucose) traverse through these end plates from the top and bottom of the disc. If it is damaged, the area calcifies and “shuts the gate,” depriving the disc of critical nutrients needed to stay healthy. This sets the stage for a slow procession of degeneration over the years which will have phases of back pain, stiffness, disc bulging, stenosis, and in severe cases leg pain, leg weakness and altered sensation.
Repetitive, axial loads to the spine. An axial force is one that travels straight down the spine, while standing. If you are in a job that requires frequent heavy lifting, especially above the shoulders; or requires you to carry 50 or more pounds of gear most of the day, you are placing axial loads on your spine. Similar to #1, it can slowly damage the vertebral end plates and damage the nutrient delivery system to the disc.
2) Hereditary Factors – there are respected studies that strongly suggest a genetic component to DDD. One study showed that there is a 50% greater chance of developing severe disc degeneration in the relatives of past disc surgery patients. Another study found mutations in the genes responsible for the synthesis of proteoglycan molecules, which are responsible for water retention in the disc. If the disc cannot attract and hold onto water, it cannot maintain its hydrostatic pressure. As a result, it loses its ability to distribute weight and slowly dessicates (dries out).
3) Occupation. This is pretty obvious. Those who work with heavy machinery or require heavy lifting are more prone to developing bulging discs.
4) Smoking. Smoking damages the fine blood vessels that the disc depends on to deliver nutrients. It also generates a lot of free radicals, which can damage the disc further. Some surgeons require patients to be “smoke-free” for at least three months prior to surgery.
So, here are the lessons to take here. First, if you have a parent who suffers from bulging discs and degeneration, realize that you have a 50% greater chance of developing them on your own. You may have a mutant gene that is making defective collagen in your disc, making it a ticking time bomb ready to go off in the near future. Your best bet is to minimize the expression of this gene, and a good way to do it is to eat as healthy as you can; ditch the toxins (smoking, excessive alcohol and sugar); avoid getting overweight, and maintain positive thoughts (may affect gene expression to your benefit).
Secondly, avoid unnecessary axial forces to your spine. Stay away from things that involve hard landings on your feet, and don’t lift weights in a way that places pressure to your lower back.
Have you been told by your doctor that you have a bulging disc in your spine? Then read on, and make sure to watch the video a few paragraphs down.
First of all, understand the following as it pertains to disc, or disk bulges:
1. Bulging discs can only be diagnosed from an MRI (magnetic resonance imaging) study, not an x-ray study. If a doctor told you that you have a bulging disc just by looking at your x-ray, find another doctor fast.
2. A certain amount of disc bulging is normal, or typical in the population. The primary function of a spinal disc is to assist the spinal column in supporting the weight of the body. Since it is viscoelastic (can change shape, due to its fluid behavior), a disc will naturally bulge outwards when standing, like pressing down on a donut. If you had your MRI in the late afternoon, gravity will have acted on your discs for many hours already (unless you were lying down the whole day, which is obviously unlikely), and will show discs with slight bulging, even when you are recumbent (most MRI machines are recumbent; i.e. the patient lies down during the study).
3. What really matters is if there is injury to the disc, and whether or not it is obstructing nerve tissue in any way.
The architecture of a disk can be imagined as a slice of an onion, but with a jelly center, encased tightly by a vertebra above and below. If an injury event causes that jelly center to punch through successive rings in a focalized (as opposed to broad) spot, but the last couple of rings remain intact, you have a disc protrusion. If the jelly punches all the way through the outer ring and is still connected to the disc, it is called a disc prolapse. If the jelly center punches through the outer ring and breaks off and settles in the spinal canal, it is called a sequestered disc.
These can be painful, as there is internal injury to the disc and the protrusion can potentially press against an exiting nerve root or spinal cord, depending where it is located. Pressure to an exiting nerve root in the lower spine most often causes same side leg pain, numbness and/or weakness. Disc prolapses and sequestered discs are usually addressed via spinal decompression surgery or discectomy (total or partial removal of disc); disc bulges are usually first handled conservatively via manual therapy and exercises.
A disc injury can also not involve bulging. An annular tear or fissure is when the rings of the disc separate circumferentially (along the perimeter), instead of split radially (outwards from center). These can be equally painful, as they are deep and difficult to heal.
If you have a disc bulge, there is still hope for recovery without surgery. It all depends on your body’s ability to heal itself. In this sense, those who have a greater chance of recovering from a bothersome disc bulge have an otherwise healthy spine: no to minimal arthritic changes, good bone density, healthy ligaments and tendons (basically, younger patients) good spinal flexibility, well-conditioned spinal musculature, and not overweight.
Here is a video of stretches/ maneuvers you can do that may help reduce the size of a disc bulge before it progresses to a surgical case. Warning, do not attempt to do these exercises if they cause a significant, sharp increase in pain. Do them slowly and pay attention to the changes in pain characteristics during the exercise. If you notice reduced pain with a certain movement, then continue.
1. Place yourself on movement restrictions for at least a few months: no heavy lifting, no jumping, no prolonged sitting, no frequent bending at the waist.
2. Eat a healthy diet consisting of plants and animals only; i.e. minimize processed food including grain foods. Flood your body with the necessary vitamins, minerals, and anti-oxidants to give it a boost as it attempts to repair your bulging disc.
3. Lose the weight, if you you are overweight. This alone will take significant pressure off of your injured disc. Eating a protein and good fat based diet along with lots of plants is a natural, healthy way to drop the pounds without having to rely on exercise too much.
4. Stretch your back frequently. Lie on your back, knees bent with feet on the floor. Take a deep breath in and gently and slowly arch your lower back as your stomach rises; exhale and flatten your back against the floor; repeat 10 times 4x/day.
Another exercise you can do is lie on your back and hold both knees tightly to your chest. Try to shape your spine in an egg-shaped curve, especially the lower spine. Hold for 20 seconds; repeat five times. Alternatively, you can get a large exercise ball (Swedish exercise ball) and lie on top of it, with your lower back at the very top. The curvature of the ball will slightly traction apart the disc.
5. Ask your doctor if you are a candidate for using an inversion therapy table. Last May, I wrote an extensive post about when to use an inversion therapy table for back pain. While this can stretch the spinal discs using gravity, it is not for everyone.
As your pain decreases, it usually means that the bulge is decreasing in size. At this point, you can do light back extensions: stand with feet 6″ apart. Place both palms behind your hips, and gently arch your back. Hold for ten seconds; repeat five times, several times a day.
Alternatively, lie on your stomach. Make a triangle with your hands (hands open, touch index and thumb fingertips together) and place under your chest. Push up (extend your elbows) and arch your lower back, while arching your neck back as well (this is called the cobra position in yoga). When you do lower back extensions, the backs of the vertebra pinch together and force the bulge towards the center of the disc.
Remember to do these exercises slowly with good form and control; remember to breathe. If any of them cause an increase in pain, it means you are not ready for them quite yet, and discontinue.
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I’ve been fielding a lot of questions about bulging discs lately. Here are some of the questions I get:
