Herniated Discs, Bulging Discs, Degenerative Discs – Possible Treatment Options
/in Podcast/by dmiddaughHello El Paso! Welcome to the Stay Healthy El Paso Podcast. My name is Dr. David Middaugh. I'm a physical therapist and I'm the owner of El Paso Manual Physical Therapy.
Today we are going to be talking about herniated discs, bulging discs, and degenerative disc disease and there are other things that happen to discs as well. Specifically, after we go over what is all this stuff and how does it happen? We will also talk about what the treatment options for disc injuries like these are. Let's just get into today's topic.
What is the difference between a herniated disc, a bulging disc, degenerative disc, or a slipped disc? There are all kinds of problems that can happen to discs. At the root of it all is a disc injury. You can get into specifics based on what doctors find, if you have ever had an MRI, if you have had a back problem, maybe you are listening to this right now, because you have a disc problem, and you want to learn more.
You might have looked at your MRI report or your X-ray report. Or you might have talked to the doctor, and they told you about what was going on. They may have used the word, you have a herniated disc, or they told you that you have got a bulging disc, or you have degenerative disc disease. There are all kinds of things that can happen to a disc.
The difference is in a herniated disc, where there is a bubble that comes out and may press against a nerve, it may press against the spinal cord. It's usually just in one section of the spine. Whenever you hear about this happening in the lower back, they can go out directly backwards, towards the middle of the spinal cord, or they can go out to the side and not affect any nerves. Or they can come out halfway between the back and the side where there are some nerves that run out the side of the back.
That can be problematic as well. Bulging disc means there is an entire section of the disk that is wanting to come out. It's being shoved out a bit, but it's not a bubble. It's like a love handle that appears on the disk.
Degenerative disc disease is when the disc itself is degenerating, it's actually becoming injured over time. You might get some hardness that develops inside the disc, there could be cracks in the disc. It's like an old disc, essentially. But you don't have to be old necessarily to get it, and they can get older at one level relative to another level. Which means that you can have degenerative disc disease at L5, for example, but not at L4 or L2, or L3. We have to ask questions about how that got there. And we will ask those questions in a second.
Another common thing that you hear about is a slipped disc. Slipped discs are kind of unicorns in my opinion, they are not really found in medical research. You might find a mention here and there. But as far as what it actually looks like it's not really a thing. The picture that people have, when referring to a slipped disc, is that the disc actually slides out of position, and detaches from the bones.
What most people don't understand is that the attachment between a disc and the bone, the vertebrae, the spine bones, it is extremely stuck. There is no way it's going to slip out. It just doesn't shove out one way or the other as a whole, it might herniate. You might get problems with the disk, but to get it to detach from the bone., I've never seen that happen or heard of that happening. Slip disc, I think is kind of a misnomer. It's not a good term to use, but it's still commonly used out in the in the medical field.
Now, why do these problems happen? And are there different reasons for each one, and in my opinion, it's usually the same similar set of problems. It's set up different types of disc injuries. It just depends on your genetics. It depends on what your spine is predisposed to, getting the type of injury that is predisposed to. If you have parents that had similar disk problems, and that's probably why you are having that.
In small cases, it can be some specific activity that you repetitively do that sets you up for this type of problem. But they all have the same root problem, there is usually a muscle imbalance between the muscles that stabilize the spine. Now, we are going to go somewhat deep here, into the root of why a disc problem happens. So follow me and pause if you need to think about the words that I'm using for a second, I'll try to keep it as simple as possible.
In a lower back, and we are talking about the lumbar spine, the lower back. You have three main muscle groups that create all this stability in your lower back. One is the back erectors, these are the muscles that run up and down the sides of your spine. On the backside is your abdominals. Of course, the abdominals are on the front, but they wrap around and attach through tendons to the spine on the back, and they also attach to the pelvis, the bones that the spine connect to at the bottom.
Then the third group would be your hip flexors, specifically your psoas muscle, which is a hip flexor, and it runs from your thigh bone, the top part of your thigh bone deep in your hip, and it comes through the front over into the pelvis and attaches up into the lumbar spine.
Between these three muscle groups, you have to have proper balance so that your spine can stay in the best position possible so that the discs can work properly. Now if you have an imbalance and your spine doesn't stabilize properly, then you are going to present eventually with one of these problems that we've talked about. Either a herniated disc, a bulging disc, or some sort of disc problem. It's just a matter of time.
Usually the thing with discs is, they are super resilient structures. They are tough. They are hard to dissect. When we have cadaver dissections in physical therapy school, those things are super hard, you can't cut through them very easily, it's actually easier to cut through the bone than it is to cut through the disk. And disk tissues are designed to be shock absorbers. So they contribute to your spine working like a spring.
Now, if you google a picture of the spine, or if you by chance can see a skeleton around you or something like that. I'm in the clinic right now, so I'm looking at the skeleton. You may not be but if you just pull up a picture of a spine, or if you think about it, if you have a pretty good memory of what they look like. All the bones stacked right on top of each other right from the tailbone. Then you have the 5 lumbar vertebrae, that all stacked on top of each other. Then you have 12 thoracic spine vertebrae that all stack up on top of each other. And then you have the neck, the cervical vertebrae that all stack up on top of each other.
Our bodies are designed to stack, we are bipedal. In other words, we walk on our two feet versus dogs or cats or cows, they walk on four feet. Their spinal structures are different than ours, they have similar components, but the way that they are designed to absorb the forces of gravity and be able to get around, there are small variations that allow us as humans to be able to stack vertically.
Now the problem comes going back to that muscle imbalance. If you have an imbalance, the one of the first things that tends to happen is the lumbar spine, the low back begins to lose its position. You'll start to curve in your back too much. You are no longer stacked vertically, and you start to curve too much. Now what I'm telling you right now is a bit controversial in the medical field, because there are all this argument about how much curvature should you have in your lower back, same thing for the neck and mid back. But I don't think that there is one specific number that everybody should fit.
Everybody is a little bit different. And depending on your body shape, if you got a smaller waist or bigger hips, or if you are pretty straight, or whatever your shape is, there are small variations with everybody. But I think the general rule to follow is that you should be pretty vertical in your low back. If you start to curve too much, then your spine starts to bend in the middle of your low back. And if you think of a spring, if you bend the spring, it wants to come back to its straight up and down position. But if you hold it in a bent position, and then you make it absorb forces, it's only a matter of time before that metal spring begins to crack or break or not work properly.
If your spine stays bent too much, what tends to give out first is a disc. The disc can take a long time to get injured, but you'll begin to see a disc bulge or herniation. Over time, you can get degenerative disc disease, and it can be painful. But that's how disc injuries are set up.
Now, treating disc injuries is a whole different ballgame. We have to figure out what the source of the problem is. Is it truly just as muscle imbalance or other things? Is there weight to account for? If it's a female, have they been pregnant? How many times if you had a C-section? Because you are pregnant, they probably did cut open your abs and you probably lost strength to your abdominals, which is one of those stabilizing muscle groups.
Now I've got to ask the question, did you ever get that strength back in your spine, if it's curved? If it's too curved, what is too curved?
That's hard to determine. Even in the medical field, we don't know. We have people looking at x-rays, and actually measuring angles and everything. It varies from individual to individual because there are so many things to look at.
What will feel like if you have a disc herniation? It tends to feel like an achyness in the lower back, it can also set off muscle spasms. A true disc problem tends to generate pain right in the middle of the back, but you can have spots of pain that appear in different areas. It might change from side to side. Sometimes the glutes can feel painful as well. You might even have pain that runs down your leg. Because sciatica is a very common side effect of a herniated disc problem.
There are different versions of nerve pain that run down your leg Sciatica is one, there is another one called lumbar nerve ridiculous apathy. That's when you have a pressure from one of those discs that's pushing on a nerve, and it sends pain down into the leg. It could go all the way to your foot.
I've felt a mild sensation of that, and I remember feeling it down into my right big toe. It was painful. It was insane. So I felt it myself. But I've had plenty of patients coming in that describe the exact pathway of the nerve that's involved. We can usually trace it back to a loose disc in their spine because it's injured.
I just mentioned those words loose disc in the spine. Whenever I'm checking a client that has a potential disc problem. I actually look at the stability of every single level of their spine. This is important because what we should find is that it's uniform that pretty much every level of the lumbar spine of the lower back moves about the same. There are small variations. But there is a general normal amount of motion that each one should have.
What I tend to find in these people, that have very arched backs, they have some sort of history of a disc problem is that where their back hurts the most. The disc between the bones and in that level of the spine, tend to be loose in the bones that attached to the disc, and will move excessively. They'll move way too much, and if I poke in that area that people will typically say, Yep, you found the spot. That's it. That's where my back hurts all the time. It just doesn't feel very good for me to poke on there. But that's what I've got to do to figure out the problem.
Other signs that people tell us is standing for too long, doesn't feel good. They feel like they need to sit down to get relief. They will lean on things, lean on shopping carts, lean on tables or countertops to take pressure off their back. They are doing that subconsciously, they don't know they are taking pressure off their back always. But it will just feel good to lean out over this way. It takes pressure off their disk.
Another telltale sign of a disk problem is people that have trouble sleeping at night because of this back pain. They usually dread turning over in bed, if they go to twist and turn over to lay from one side to the other side or move on to their back or their tummy. It tends to kill them quite a bit. That's a more extreme example. But you do see that general twisting motions tend to not feel good. People who have children, for example, getting kids in and out of their car seats can be painful for them. Doing laundry, having to twist in awkward positions to get into a washing machine, or a dish washing machine as well.
That tends to be pretty uncomfortable on a back problem. They tend to not be able to stay bent over for any period of time. They usually are decently flexible, they can reach their legs or toes, even sometimes they even reach the floor. They don't tend to have a big flexibility problem. They may not be the most flexible person in the world either, but they don't report that they are inflexible. They have pain though, if they are staying in a bent over position for a long time, or if they are having to lean over and hold it for a while.
Some of these people tend to feel better when they lie on their stomach. It relieves your back problem versus lying on their back. They don't like it too much, especially when their legs are straight. They feel like they are very uncomfortable. When they lay on their back and their legs are straight, they have to bend them up, and bend their knees so that they can take pressure off their back.
Notice I keep saying take pressure off the back. That's really what is causing the problem, there is excessive pressure because the spine is bent and it's aggravating the disc problem. So if you get that excessive rotation that happens in the spine because it loosens if you are bent too far, and you walk like that, you live like that, you move like that, you start to rotate too much at that level of the spine, wherever the disc injury is at and it creates an instability at that disc over time. That's typically what sets up people for a bulge, or herniation. Or some people don't get that, they get degeneration over time.
Now, a big question that people frequently ask, whenever they come in for help with a disc problem is, can my disc heal? It's very confusing out there. And what I want to tell you is there is some research out there that shows that disc tissue can heal. There is no research out there that I've found conclusively that says that discs don't heal. What the research does say is that people with disc problems tend to not improve their discs. But that doesn't mean that there isn’t something out there that can make them heal.
There is evidence of discs healing, so I hope that's not too confusing. Just to say this one more time, there is no research that shows a disc can't heal, but there is research that disc can heal. And there is research that people that tend to have a disc problem basically tend to not do the right things to get better. So there is evidence that people don't get better is what it is.
Now, on the topic of disc healing, what we know is that it takes about a year for discs to heal, and it is possible to put scar tissue down in a injured disc area. As long as the disc isn’t injured so severely that it's pushing on a nerve, it tends to get better without surgery.
If you think that you have this problem where its pushing on nerve because it's so painful. That might be the case but in people that that actually need surgery, the pain will be debilitating. I mean to the point where they cannot move, they cannot function. In very extreme cases, they are having accidents like a bowel and bladder accidents, like they are pooping and peeing themselves. I have seen a couple of those cases and they don't look very dramatic. What they tend to say is I've made it to the bathroom, but it's real close. There has been sometimes where I actually get myself a bit dirty. But I usually am able to hold it longer and get to the bathroom just fine.
If that's happening, if you have those kinds of symptoms, if you got debilitating pain down your leg, you need to go to the doctor and get a MRI, likely they'll tell you what to do, you actually might need a surgery. But if it's just back pain, and I say just back pain, it could be very painful back pain, but you are not having any bladder problems, or having debilitating pain that doesn't let you even stand up or walk. It could still be limiting you from sleeping enough at night. It may not let you be comfortable when you are driving, you may find that you need pain medication and extra help from the doctor. Those types of back situations almost always can get better without having to have a surgery.
Now, let's talk about what the treatment options are for a disc problem.
The most common place that people start, whenever they visit their doctor for a disc problem is, they get offered pain medications. This could be muscle relaxers, it might be strong heavy-duty pain medications, or the doctor might even recommend over the counter pain medications. And many times, that's enough to take the edge off so that people can function, work, take care of their family and kids, and get them through a flare up.
But if this back problem isn't handled properly so that it's getting better for the long term, it's usually just a matter of time before it flares up again. You have to make sure that you take the proper steps to manage this problem for the long term.
Other things that doctors will recommend are back support braces, they sell them at a drugstore, and sometimes even grocery stores have them, or you can get them online. There are special ones that you can cinch down real tight. Those tend to be pretty helpful for disc problems, but they are short sighted, they don't fix the problem for the long term. You have got to fix that muscle imbalance.
Usually there is some weakness within the muscle groups that stabilize the spine. There might be some movement problem as well. There is usually a slew of problems that all come together to create a disc problem. But wearing a back brace might allow you to not take as much pain medication.
The next thing doctors will often offer are injections for your back. They will inject corticosteroid pain medications, pain medication and an anti-inflammatory medication straight into your back so that you can have less pain and they are pretty effective. Most people report having immense pain relief for up to a few months. The thing is, they don't last forever, some people will flare down and they get a longer benefit of pain relief. They might be good for six months or a year, but we often hear the story where people say, yeah, I've had this back problem for almost 10 years now. I usually can rest it off, I usually can do some stretches, I usually can go to the doctor. If it's really bad. They'll give me an injection and then I'm good for another six months, or another year and then it just keeps happening over and over as the years go by.
They keep self-managing with injections, with pain medication, and with exercise that stretches those kinds of things. But meanwhile, their muscles aren't getting more in balance, they are actually getting worse. And they are working on a disc injury, on a herniated disc, or a bulging disc, or they are creating degenerative disc disease in their spine. It's just a matter of time before it starts to really be bad to the point where it can be debilitating. You have to be careful with those injections as well. Use them as short-term pain relief, but make sure you work on a plan for the long term.
There are a couple of different surgeries that are commonly done. There are more than these two that I'm going to mention, but these two are the most common. The first one is what's called discectomy. This is the minimally invasive surgery that's done out there. And the reason why they say that is because they just make one or two small incisions, and you actually leave the office the same day. You don't have to stay overnight, usually in the hospital, and they can sometimes put a Band-Aid over the incision and that's all you need to heal from the incision site. That's why they call it minimally invasive.
But they do go all the way down deep into your spine right where the disc is at. And they cut off the chunk that's bulging, or they shave it down, or they remove the part that's herniated in the clean up your disk so that it's more normal shaped. They are taking out disk tissue.
If you have that really severe pain that's going down your leg and you are having tons of trouble, it might be what you need. But you got to be careful in thinking that this is going to be the last time you are going to deal with this back problem. Because if you haven't worked on your muscles, your strength, the way that you move, fix the underlying root problem for your back, then it's likely going to come back. We often see people that have had multiple discectomies.
I had a client in fact, who already had two and was on his way to have in his third. His surgeon was recommending a third discectomy in his back. But he didn't want to do that again, because obviously the first two hadn't worked. All this is within a year and a half timeframe from when he had his first one. He came to me to try doing an alternative physical therapy. And he had done physical therapy as well. But he had done a type of physical therapy that had a different kind of focus than what we have here.
Here at our clinic, we figured out his muscle imbalance, we figured out what joints were stiff, which ones needed to be stabilized, went through the whole process. And by the end of his treatment plan, which we saw him for about four months. He actually was weightlifting. With a barbell, one of those big long weight bars. With 135 pounds on his back, we loaded up his spine. And the reason why we got to that point was a cool thing that happens in discs in your back and really all tissues in the body as they adapt to forces.
We got this guy to the point where his back was no longer flared up. He was saying, I don't have any pain, I feel fantastic. I can bend over, I can stand, I can walk, I can even jog a little bit. We really tested him before we put any weight on him, and he's a big guy. He used to play football. He's has a pretty big frame. So he's able to take some weightlifting just fine. You could tell his body is built for it. We put a little bit of weight on his body and we had him do some squats with like 10 pounds, and then 20 pounds, and we worked his way up gradually. He sped through it and I was making sure that he was safe and that no adverse reactions were happening.
We worked on this form and his technique, and he had corrected his muscle imbalance to the point where he could squat and load his spine so that his disks can feel that pressure and the cells inside the disks can detect it and tell each other to get stronger and denser so that they get healthier.
Just like your skin will get calluses, if you are weightlifting or doing yard work, or house work that makes your skin get calluses around your feet as well. People get calluses on their feet all the time. That's the skins response to extra forces that's put on it so that it protects itself and makes it so that it's safe to do that activity again, without tearing your skin. If you get callus, that's good, because you didn't break your skin or get a blister, it wasn't too much activity too fast, because that's what will break your skin. Obviously, it was a tolerable amount for the skin.
We do the same thing in the back if we if we load the spine. Once it's all healthy, in a way that's tolerable, little by little over time. You can work your way up to where you are actually creating a protective amount of strengthening through the disk, but you have to lift weights to do that.
I just want you to be careful if you are out there and you got a disc problem. Please don't jump straight into weightlifting, like the story that I told you, you have to take it a step at a time, get expert help, make sure you are working with somebody who knows what they are doing, how to fix these muscle imbalances that we are talking about.
Don't jump straight into it. I'd be careful to working with a personal trainer as well, just because depending on their background, there are some trainers out there that are pretty good at what they do, but they may not have a full understanding of all the anatomy and the physiology. and the way that all this stuff works together. Their version of a squat may not be what you need. So you got to make sure you find the right kind of help to get to what you want to do.
That's just one story. I've got tons of other stories of people with severe disc injuries that are doing just fine now, even lifting pretty heavyweights.
Now, with surgery, and we were talking about the discectomy, the second most common surgery, if discectomy is not an option, or they've already tried them, and they haven't worked. The next most common surgery is a spine fusion.
When they do this, there are different ways they do it. But the most common one is where they put rods and screws into the bones of the spine to maintain the space of the disk and offload the disc, but at the loss of being able to move at that spine, that's why they call it a fusion. So those bones are essentially fused together through the hardware that's installed and it no longer allows movement at that level of the spine. It preserves the nerves and allows the pain to go away.
It's a miracle surgery, it really can make a huge difference. When done for the right person. There are people that lose the ability to walk because of a spine problem. And once they get a fusion done, and they can walk again because the nerves had the pressure taken off and they are normal.
If it's that bad and you need a spinal fusion surgery, then of course, consult your doctor and let them make that determination. But there are natural ways to take pressure off your discs using your own body, and there are ways to maintain that over the long term. And as we discussed, with weightlifting you can make your discs more dense.
My advice to you is, if you are dealing with a suspected disc problem, get started on getting help early, don't let it go on forever, don't let it fester and get worse and worse and begin to affect other things. Because it will create a nightmare situation for you. You don't want to have multiple surgeries or any surgeries for that matter. You don't want to have to be getting injections all the time and relying on pain medications, having to rely on putting on a brace all the time. You don't want to be defined by your back problem. You don’t want to be that person that is always talking about how much their back is bothering them.
I'm sure you'd much rather enjoy your work, your family, your life and be able to do the things that you want without your back bothering you.
So lastly, the next most common treatment for back problems is physical therapy. There are different types of physical therapy. I just wanted to highlight what we do here in the clinic at El Paso Manual Physical Therapy. Our specialty is manual physical therapy.
What that means is by hand, we spend a lot of “hands on” time with every client. And because we are by hand, moving every bone in the spine and checking it to make sure that it's moving properly. We look at the soft tissue, in other words, the muscles, ligaments, tendons, nerves, that might be affecting the situation.
We take a holistic approach when we are looking at the entire body, not just low back. Because oftentimes there is a hip problem that's feeding into the back problem. There is an upper back problem that's creating more pressure in the lower back, and even down into the knees, the lower legs, ankle and feet, we need to look at that as well. When you talk about the way that you are walking, about the way that you are running, or doing any other activity, we need to go in depth, and make sure that we address you as a whole person so that your back problem can get better for the long term and stay better.
That way you have the most control over your back, you know what to do, you know how to keep it healthy. If it ever starts to flare up on you, you know exactly what you need to get back to doing.
Physical therapy is amazing for back problems. You just got to make sure you find the right physical therapist that fits your needs. And that might just take a chance or two. You have to try different people, different companies and see what you like the best. There are different types of physical therapy clinics out there. And by and large, most of them focus on helping people after surgery. So if you have had a knee replacement or a back fusion, like we talked about a discectomy. Like we talked about meniscectomy and your knee, that's another type of surgery similar to a discectomy.
Going to these clinics that handle a lot of cases after surgery is a great idea. But if you haven't had a surgery, then going to a clinic that tends to see more cases that have just had surgery might not be the best idea, because they are just not going to be best suited to help you out. You might look out and find somebody that's great. But more often than not, you might end up doing very similar exercises to the people that just had surgery because that's how their systems are. H
Here at El Paso Manual Physical Therapy, we rarely see any surgical cases. We tend to help people that are just looking to avoid surgery. They haven't had surgery recently in the past, or they might have, and they just don't want the second or third surgery. But we are looking at people without them having had a surgery, so we are trying to fix a problem from getting worse, to the point where they need injections, they need to be relying on pain medications, and need a surgery. So be sure to do your research when looking for the right kind of help.
Thanks for listening guys. I hope this was helpful for you. I hope you know all about disc problem now and you know the best information so that you can make the best decision about how to move forward in helping your discs heal for the long term. Have a wonderful day. Bye.
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