Disc Injuries...What do you know?

We’ve all heard of someone who herniated a disc, bulged a disc, or perhaps they “slipped a disc” (which isn’t really a thing). Chances are you have experienced one of these. In the next 3-5 minutes I want to clear up some confusion about disc injuries and give you some advice that you can use to successfully treat your lower back pain.

First off, discs don’t “slip” in and out of position. They can, however, bulge, herniate, and tear. This is typically the mechanism through which much of society experiences low back pain - from the disc, or what we call in the biz discogenic….which is fancy latin speak for “from the disc”.

So what is a disc bulge and what is the difference between that and a disc herniation? Confusingly, disc bulge and herniation are two words for the same pathology. They are not different phenomena. Wouldn’t it would be nice if the medical industry used terms consistently?

To explain what a disc bulge is, I need to briefly cover the anatomy of the disc. You can think of the disc as a jelly filled doughnut with really thick walls. The jelly is a thicker, toothpaste like liquid called the nucleus pulposis, which is surrounded by many layers of concentric collagen rings called the annulus fibrosis. (See image 1).

The intervertebral disc is profoundly important for 2 main reasons. First, it acts as a shock absorber. Second, it allows the spine to move, which, as you can imagine, is quite important. Without the intervertebral disc, our spines would be rigid - greatly limiting our function - and subject to copious amounts of stress fractures.

When the discs are compressed, whether by gravity, our own muscles, or ground reactive forces, the fluid in the middle (nucleus pulposis) is dispersed outward into the surrounding annulus fibrosis. Against this outward-pushing force, the annulus stretches. In a neutral position, the outward-pushing nucleus pulposis evenly stretches the annulus throughout the entirety of its circumference. If, however, the spine bends excessively in one direction, the outward pushing force disproportionately stretches one part of the annulus. This is how a bulge or herniation occurs. When the spine is bending, particularly with a heavy load, the force stretching the annulus is strong. Over time, the annulus will stretch, eventually permanently distorting. Once distorted, it will “bulge” outward (hence the term), resulting in the disc herniation one can see on an MRI. While this does not always cause pain, it often does. The direction of spinal bending that most often results in a bulge is flexion (bending forward, like tying your shoes).

Confusingly, it is often not heavy lifting that produces disc bulges; it is repetitive flexion and/or sustained flexion for long periods of time, like we all do when we sit. While the load may be light, sitting for 4, 6, 8+ hours a day places a chronic stress on the annular fibers of the disc, which ultimately cause the bulge.

Okay, so we know that a disc bulge is when the annular fibers of the disc stretch to the point of distortion and we know that this most often results from bending the spine excessively forward (whether by load, repetition, or duration). We also know that, while disc bulges can and do cause pain, having one is night a life sentence for such. Typically, patients with disc bulges can get out of pain with some therapy, rehab, and lifestyle modifications.

Now to the good part, what YOU can do to manage or even treat your lower back pain.

First, you can try to stand more. This might seems overly simple, but it is hugely helpful for most types of lower back pain. I typically tell patients that you want to stand more than you sit. If you are used to sitting all day, just work into it. You can start with short breaks every 30-60 minutes and work toward using a standing desk all day. I, myself, do not have a sitting work station. The desks in the treatment rooms, in my office, and at home are all standing. I am actually standing as I write. As someone who has experienced his fair share of lower back pain (can you say irony?), I can confidently say that transitioning to a standing desk has had a hugely positive impact on my lower back. This intercession is as powerful for addressing lower back pain as it is easy.

Second, when you have to sit, do your best to have a pillow behind your lower back for support. We all have to sit (eating with the family, meeting with a colleague, driving, etc.). Having support for your lower back in these situations is very helpful. If you are in a lot of pain at the moment, I would ALWAYS have support. If you get occasional lower back pain, I would use support when you can. At home, one can simply use a throw pillow (conveniently called a lumbar pillow). In the car, I suggest you use a McKenzie Roll (Image 2), which can be purchased at our office or on the internet. If you get lower back pain with sitting, this is well worth the money, especially if you have to drive a lot.

Finally, you can perform a powerful exercise that comes from the McKenzie Institute (through which all of the CCRC physicians have been trained) called the Press-Up (Image 3). You simply lay on your belly with your hands just outside of your shoulders. Carefully extend your elbows, pushing your chest away from the floor, until they are straight. This is done with your back and hips as relaxed as possible. I would suggest starting with 10-15 reps 3-5x throughout the day. Listen up here, if for whatever reason, you feel like you back is getting worse from the press-ups, stop performing them and seek a professional medical opinion. While the press-ups will help the vast majority of patients with lower back pain, it is not for everyone. For a video of Dr. Kraft explaining how to properly perform a press-up, click here: www.youtube.com/watch?app=desktop&v=lhHLL_uteRc.

Whether you have a disc bulge or not, whether you have been treated for lower back pain or not, if you are experiencing lower back pain, these 3 interventions will likely have a huge impact of your symptoms. If you come into the office, there is a strong chance that you are told to do these at home, no matter which physician you see.

I hope you found this useful. If you have any questions, feel free to contact us!

Keep Moving!

Dr. Richard Ulm, DC