Tamato, tomato….it doesn’t matter what you call a lumbar disc bulge, it still hurts! The intervertebral (in between the vertebrae) discs act as shock absorbers for the spine. They are found in between each of the vertebrae, from your neck down to your back. The discs transfer load from the ground up, as you hop, skip and jump through your day. If you injure the discs in the lower back it may slip towards the spinal nerves. This common lower back injury is also known as a disc herniation or prolapse.

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What are the discs in your lower back made up of?

Spinal discs have outer fibrous rings (annulus fibrosus) with a softer jelly like substance inside (nucleus pulposus). Almost like jelly enclosed in an onion. The outer rings are made of strong collagen fibres, while the inside has a soft consistency. Together they form a shock absorber and increase the movement of your spine. During normal movement the jelly moves to absorb the force. When you bend forward to touch your toes, the jelly inside gets pushed backwards. The outer ring contains this gel and restricts movement out of the spinal canal.

If the annulus is injured, the nucleus may slip out of position, and cause a lumbar disc bulge or herniation. Commonly a slipped disc in the lower back happens when some of the annulus fibres are injured, and the nucleus bulges into the direction of the injury. A disc herniation occurs if all the fibres of the annulus are torn and the nucleus can protrude into the spinal canal.

It all boils down to agonizing pain. The tell tale sign that you might have a disc injury in your lower back is if you are unable to bend forward to pick up something or put your shoes on, due to excruciating back pain. The disc literally protrudes into the intervertebral foramina (where the nerves leaves the spinal column to travel into the back and legs) and press on a nerve, causing severe nerve pain. Discs may “slip” into different directions. The direction of the disc herniation will determine the severity of your symptoms.

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Cause of Disc Bulge

The injury happens when you put too much load through the disc. This can force the jelly in a certain direction. Think lifting a heavy box from a bent over position. The jelly is pushed backwards (as you bend your spine forwards), then you pick up the box. This excessive force causes some of the outer ring’s fibers to tear. This tear allows the gel to push out further than it should and pushes onto the spinal cord or nerve roots. You will feel sharp pain in the back and may be unable to stand up straight. This is as a disc budge or a slipped disc.

The cause of the slipped disc is the small tears in the outer ring (annulus fibrosus) that allows the inner gel (nucleus pulposus) to push out and put pressure on the spinal cord or nerve roots. Repetitive movements, like bending forward and turning when you hang the laundry, can progressively weaken the outer ring and make it more susceptible to bulge under high load.

Cause of Disc Herniation (slipped disc)

A disc herniation happens when a lot of the outer ring’s fibers are torn. The jelly pushes out, to the point where it cannot return to its normal position. “Hernia” means “abnormal displacement or protrusion”, in this case of the disc. The disc essentially “slipped” outside its normal boundaries. The disc now pushes onto the spinal cord or nerve root. This will cause severe pain, not only in your back, but also of the nerve and can refer into your leg. The surrounding tissue will be inflamed and swollen. This swelling will put even more pressure on the disc and surrounding nerves and cause more pain as a result.

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Symptoms of Disc Bulge

  • Dull band of pain over lower back
  • Sharp stabbing pain when bending forward
  • Sudden pain
  • Pain while sitting (driving)
  • Sharp pain when changing positions
  • Coughing causes pain
  • Sneezing causes pain
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Symptoms of Disc Hernia

  • Constant sharp pain
  • Pain when sitting or driving
  • Unable to bend forward (touch toes or put on shoes)
  • Electrical sharp pain when bending forward
  • Muscle tightness or joint stiffness
  • Start suddenly or slowly get worse
  • Pain and stiffness when getting out of bed
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Pinched nerve

There are two different types of disc herniations.  These types refer to the direction that the disc has slipped to. Your symptoms will be determined by which nerve is pinched.

Central Disc Herniation

The disc in protruding into the centre of the spinal cord.

This type of disc herniation affects both legs equally. Symptoms include pain, numbness, weakness and pins/needles.
This could cause narrowing of the spinal column (spinal stenosis).

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Posterolateral Disc Herniation

“Posterior” means backwards and “-lateral” means away from the middle (either left or right).
The herniated disc protrudes backwards and to the side. This puts pressure on the nerve root (where the nerve exits the spine). These types of herniations cause pain down one of your legs, along the path of the nerve that is pinched.

Pinched nerves in your lower back spine can cause pain in your back, and ‘referred’ nerve symptoms (pain, pins and needles, numbness, weakness) in the area that the nerves supplies. (See the dermatome chart to determine where the nerves run.)

When is surgery needed?

If conservative treatment fails to relieve your symptoms (the inner gel sac is not moving back into its normal position for healing to take place) we will refer you to consult an orthopeadic surgeon. The surgeon will send you for an MRI scan where he will be able to see the disc hernia and determine a course of action.

We have found that in most surgical cases, the patient failed to comply with treatment and ignored the advice provided by the physio, leaving the program incomplete and the patient frustrated.

The removal or replacement of a disc is called a discectomy. “-ectomy” meaning removal or partial removal. The other option is a laminectomy, where part of the vertebral bone is removed to relieve the pressure of the nerve.

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Physio advice

  1. Sit well. You should always maintain the slight backwards curve of your low back when sitting. Most office chairs offer some form of lumbar support for this reason, even a lumbar roll makes a good alternative if your chair has a straight back rest.
  2. Reverse your curve. If you are spending a lot of time in sitting or bending positions, spend some time arching your back backwards every hour or two.
  3. Stay strong and check your technique. Exercise such as pilates or weight training can be a great way to strengthen your core. Remember that when you’re lifting things, the goal is to keep a neutral spine. If in doubt, ask us.
  4. If you suffer an episode of lower back pain, get to your physio sooner rather than later. Many people suffer with symptoms for far too long simply because they did not seek help at the beginning.

Physiotherapy treatment for a disc bulge and herniation

Disc bulges and herniations respond to the same treatment techniques.

Treatment during the acute phase

Our first aim is to relieve your pain. We use myofascial techniques and electrotherapy (TENS, laser) to decrease protective muscle spasm and the surrounding inflammation. Then we aim to create more space for the nerve root and the disc, by using joint mobilisations. You will be given home exercises to increase circulation to the nerve and decrease pain. We will immobilise the back with strapping to prevent you from doing anything potentially harmful (bending forward).

Intermediate phase

As treatment progresses, we may make use of deep dry needling to sort out any residual muscle spasm. You will now be able to move more comfortably. Now we can include rehabilitation exercises to strengthen your core to prevent a recurrence of your injury.

Final phase

You will have little or no pain now. You wil be able to move comfortably and get back to your daily activities or sports. Rehabilitation is very important for maintaining your strength and mobility now and prevent recurrence in the future.

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Why a slipped disc takes a long time to heal

The intervertebral disc has poor blood supply, compared to that af a muscle. Only the outer third has small blood vessels (capillaries). Nutrients and oxygen rich blood is limited, and will take a considerable amount of time to heal, even after the pain has subsided. Approximate time to heal is between 3 to 6 months.

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