Herniation of the intervertebral disc of the spine is a health problem wrapped in legends. Public opinions and discussions on this subject are often based on stereotypes that have nothing to do with medical reality. It is important to understand that a disc herniation is not a disease, but only the consequence of certain musculoskeletal disorders, and therefore is only the tip of a slippery iceberg. Much more important is not the verdict of a disc herniation, but the question - how to live with it, or, better yet – without it!
Congenital or acquired
It is a stereotypical claim that a disc herniation is genetically programmed and its emergence is inevitable. Jonas Girskis, physical medicine and rehabilitation doctor, neurologist, and specialist in manual therapy, based on medical science and his almost 40 years of disc herniation treatment practice, disagree with this popular myth in society: “I would like to remind those who think this way that a person is genetically programmed to die. So maybe we shouldn't offer medical education in universities, build hospitals, develop health strategies so we would not stand in the way of those leaving this world?” Such critical rhetoric is summed up with the fact that a disc herniation is acquired: it forms gradually when there is a disorder in a musculoskeletal system. The latter, by the way, gets our attention only when we start feeling pain or other unpleasant sensations. Knowledge of the biomechanics of your body could help you to get ahead of the pain and to prevent these problems.
According to Rūta Burzdžienė, physical medicine, and rehabilitation physician, we must understand that disc herniation is rarely a consequence of a "single lift". The structures of the human body are very strong and for them to rupture and tear enough to compress the nervous structures, it usually has to be exposed to irregular friction and loads for a long time (at least a few years) that disrupt the nutrition to the disc, elasticity of the disk and make it vulnerable. "The formation of a disc herniation is influenced by everything – genetics (how strong the connective tissue, the tendency to degenerate faster, what type of posture, muscle tone) and ergonomic habits (how we sit, walk, lift objects) and, perhaps most importantly, daily body care habits (whether we train, exercise our body which is programmed for movement, or just use it, ignoring the parts of our body that are loaded the most and that need extra attention). Each crack of the disc provokes a painful back spasm. If we alleviate the pain with medication, the muscle imbalance continues to develop until eventually the fibrous ring of the disc ruptures and the soft nucleus erupts from it. This final step - the rupture of the disc - depends on the situation that would sooner or later happen to such a weary disc,” explains Dr. R. Burzdžienė. For some, the rupture occurs during sports or when lifting or pushing something, for others – when bending to tie a shoe, for others - after a lot of stress or prolonged sitting, or even when coughing heavily due to some other illness.
How does a herniated disc happen?
A spinal hernia is a health condition in which the gel-like mass between the two vertebrae (the nucleus of the intervertebral disc) bursts through the weakest point into the spinal canal or into the openings between the vertebrae where our spinal cord and nerve roots hide. The erupted gel-like mass often compresses and irritates those nerve roots. Depending on the type and degree of the hernia tissue compressed and the degree to which the patient's musculoskeletal system is unbalanced, the symptoms range from complete numbness to severe pain, movement, and sensory disturbances. Perhaps most commonly felt acute, stabbing lumbar, thoracic, or neck pain, spinal movements become painful. Innervated by a compressed nerve the pain spreads to other parts of the body: arms, buttocks, legs, ribs.
First of all, it is important to emphasize that the formation of a disc herniation is slow and long process. It is also true that a disc herniation can occur suddenly, due to an injury, but even then, it is most likely caused by a pre-existing disorder in the musculoskeletal system.
Jonas Girskis, physical medicine and rehabilitation doctor, neurologist, summarizes the formation of spinal disc herniation: “First of all, the factor of irregular movement in our body causes differences in muscle tension. Over time, this changes the axis of the spine and the position of the joints, resulting in irregular directions of gravitational force to the intervertebral discs and joints, which are constantly traumatized. The fractures in the fibrous ring of the intervertebral disc increase. As a result, the disc swells, protrudes beyond its anatomical boundaries, and encounters the nerve root of the spine, which gets episodically irritated. Eventually, the fibrous ring of the intervertebral disc ruptures. A soft nucleus erupts through the cracks and compresses the nerve root. The formed disc herniation causes spasms of the muscles around the spine, overstretching the surrounding ligaments. And the circle of flawed consequences takes off: the spine is twisted to the side, and it is often turned around the longitudinal axis. Biologically active substances that irritate pain receptors erupt from the intervertebral disc. All this causes pain and other unpleasant sensations. "
Pain is a consequence, not a disease
Thus, the pain caused by an intervertebral disc herniation is only a certain negative consequence, which is caused by a long-term disorder in the musculoskeletal system. In addition, according to doctor J. Girskis, not all back pain is caused by a disc herniation. Back pain may be caused by an increase in the tone of muscles, tendons, and ligaments or a change in the position of the joints, and the irritation of their mechanoreceptors. "After diagnosing a disc herniation, doctors sometimes seem proud of such a discovery, while a usually proposed operation is hardly the best solution. First of all, it is necessary to look for the faulty biomechanical circuits that caused the formation of the disc herniation, and to treat those faulty circuits as soon as possible,” explains Dr. J. Girskis.
According to a musculoskeletal system specialist, first of all, it is necessary to restore the impaired physiological spinal joints movements. The nutrition of the disc and at the same time healing depend on them. When physiological movements recover in the spinal joints, the discs between the vertebrae eliminate the consumed metabolic products and absorb the necessary nutrients. The healing disc herniation is not visible - the healing process is assessed by the disappearance of some specific symptoms: reduction of pain, recovery of tendon reflexes, strengthening of the muscle innervated by the damaged nerve, and so on.
People exhausted by the pain just want to surgically remove that pain – a disc herniation, because they think that the pain will stop and will not return. Really? What does the musculoskeletal system have to do with disc herniation? Well, finding faulty links in the musculoskeletal system allows the hernia of the disc to heal naturally. Thus, one should first look for repairable elements of biomechanical chain rather than take a scalpel. Why? Because after the surgery, the problems that caused the disc herniation will not go away. A disc herniation is not the same as a damaged tooth – when you remove it, the source of pain disappears. On the other hand, a good dentist will make every effort to preserve even a damaged tooth. Thus, a disc herniation does not always have to be surgically removed.
First of all, the cause of the problem is usually hiding in the musculoskeletal imbalance. “Magnetic resonance imaging, unfortunately, only shows the conflict between the nerve root and the ruptured disc, and this conflict is taken out of the context of the whole body. This problem/conflict should be assessed only after a thorough examination of the musculoskeletal system, - explains Dr. J. Girskis. - The first step is to look for and find the muscles of the body that are too tense or too weak as well as articular joints that do not perform their function. Then we can start rehabilitating the impaired biomechanical chain with carefully selected appropriate healing movements.”
Often neurosurgeons have to explain to the patient why nothing has changed after the operation or why the condition has become even worse. Therefore, there is no need to rush and it is important to evaluate other treatment options before surgery. Urgent disc herniation surgery is required only in several specific cases - when a threatening syndrome caused by the hernia develops, causing disorders of the pelvic organs (urination and bowel movement), numbness in the buttocks or around the genitals. Each situation needs to be critically assessed before prescribing surgical treatment.
Restoration of biomechanical balance
“We successfully treated hundreds of patients at our Spine treatment center who have previously been scheduled for surgery but reconsidered. They achieved excellent results thanks to their persistence, willpower, and correct application of physical medicine and rehabilitation techniques.
First of all, we must look for impaired biomechanical links in the musculoskeletal system, and then next step - we should use biomechanically targeted therapeutic exercises – physiotherapy. I must emphasize, by no means should we use general exercises that are intended for physical activity, but not for treatment," says Dr. Girskis.
Dr. R. Burzdžienė based on her professional experience gives the answer to the frequently asked question about how long it takes to restore biomechanical balance: "The duration of treatment depends on the patient's motivation because it is up to a person how much work he/she will put in to correct the musculoskeletal imbalance that has become the cause of the disc rupture. It is also important how much pressure the nerve root is under and how skilled his/her physician is. In this case, targeted therapeutic exercises are necessary. Although the pain may decrease after a few weeks or months, the correction of the musculoskeletal system and the restoration of normal body biomechanics may take years and longer.”
So, the first action when you hear the diagnosis of spinal disc herniation is assessing the biomechanics of your body. The better we understand the problems that arise and know how to deal with them, the milder the effects of the disease will be.
Typical symptoms of a herniated disc
Pain with the most common lumbar spinal disc herniation usually occurs low in the lumbar-sacral region. Depending on the size and position of the hernia, the pain can spread to the buttocks and legs. About 95 percent of cases disc hernia is located between the lumbar the fourth/fifth (L4/L5) and lumbar fifth/sacrum first (L5/S1) vertebrae.
In case of S1 nerve root damage, the pain spreads to the posterior surface of the buttocks, thighs, calves, outer edge of the foot, little toe. Numbness may be felt in the little toe, outer ankle.
If the L5 nerve root is damaged, the pain spreads to the upper buttocks, the outer thigh, the front of the calves, the back of the foot, and the big toe. The area around the big toe, the inner ankle may become numb.
When the L4 nerve root is damaged, the pain spreads to the anterior surface of the thigh, the inner calves. Damage to the L2 and L3 nerve roots is rare.
Also, disc herniation can form between the neck vertebrae and very rarely – the vertebrae of the thoracic spine.
How to distinguish a disc herniation from other back pains?
First of all, does it need to be differentiated? If your back hurts, then the levers/tensions in the body do not come together as they should. The longer the irregular stresses affect the structures of the spine, the more the consequences become obvious – we can see various changes in radiological examinations. Treatment should be started with the first signs of discomfort instead of after diagnosis of a disc herniation.
A sudden, larger rupture of the intervertebral disc usually forces the body to protect itself against nerve constriction and causes an antalgic position of the body – the body twists, "brings" the hip to the side. Trying to get back to a normal position causes pain. As the tissues gradually heal, the posture usually recovers.
Also, pain in the leg (more pronounced in buttocks, calves), numbness in the foot, impaired foot motor skills ("shuffling foot", or failure to tiptoe), indicate intervertebral disc herniation. The nerve root is pressed in the opening through which it passes from the spine to the leg.
Often in the case of an intervertebral disc herniation, patients complain that pain in the lumbar area or leg wakes them up at night and they have to get up, walk around, exercise to get little relief. After the night, the body feels stiff, it is hard to move, to put the socks and shoes on. Immobility and axial load, such as prolonged sitting during the day, provoke similar difficulties, so patients also during the day have to often change position, try to walk around.
Atypical symptoms of a hernia
Most symptoms are clear and fairly typical for the doctor, especially after examining the patient's body: assessing neurological symptoms, determining strengths and tensions of the muscles, identifying what movements (muscle tension, nerve tension, or joint reaction) restricts the body. However, sometimes patients don’t realize that the pain and numbness of the whole leg or calf that prevent them from a good night's sleep are caused by a disc herniation. Or that the pain, even though the hernia does not disappear, can change depending on the activities – increase while sitting, or pain can start in the leg when walking for the first minutes, and decrease as you walk.
Confusion is often caused by the pain in the buttocks or legs without the back pain. Then, to rule out foot ailment, vascular surgeons, orthopedists, rheumatologists, and so on are first visited. Occasionally, pain due to the iliopsoas muscle tension or irritation of the higher nerve roots spreads to the lower abdomen. Therefore, internal organ diagnostics, gynecological examinations, etc. are often performed before the visit to a spinal treatment facility.
In the case of a large hernia, which severely narrows the spinal canal, there may be difficulty or inability to urinate, "saddle-type" numbness of the genitals and the inner thigh. These symptoms are rare but very serious and should be treated urgently by a neurosurgeon.
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