Lateral Disc Herniation

aka FAR lateral disc

Keywords: Lateral Disc Herniation, chiropractic help, femoral nerve damage, help for sciatica pain

Far lateral prolapses and extrusions are an enigma that often baffles the chiropractor and medical doctor alike. Why?

Please accept that this may be a bit of neuroanatomy that may be beyond the interest of the average patient, but what is important is that the herniation is one level lower than that expected.

Why is that important? Because, with 33 years of examining patients with lower lumbar back pain, I can tell you that is often not clear whether the herniation is a L4-L5 Lumbar Spine lateral disc protrusion, or L5... Or L3. Double hernias are not uncommon too just to add to the confusion.

Usually when there's sufficient wear and tear at a particular level to rupture the disc, there's also degenerative change at several other levels, each of which will be contributing to the mayhem.

Take this scan for example (see Femoral nerve damage ... for more details, if interested): Only seen on the axial views is that there is a very large extrusion from the L3-L4 disc, part of which has sequestered posteriorally into the spnal canal, but just look at the L4-L5 disc.  Both discs would be painful.


And, because the "far lateral" is far beyond the usual cut of the MRI, it is often missed by the radiologist, and a 'normal' report is sent to baffle your chiropractor and your doctor.

What is it?

Most herniations occur into the spinal canal (usually contained behind the Posterior Longitudinal Ligament) or into the inter-vertebral foramen (IVF) where the nerve exits. However the (Far) Lateral Disc Herniation ruptures beyond the foramen, and traps a higher nerve than expected.

Because the Lateral Disc Herniation is less common it will have your chiropractor scratching his/her head. You see, the pain pattern in your leg with a the lateral disc doesn't correspond to either his findings, or what may or may not be seen on the X-rays and scans. It just ain't following the proper radiating pain that it ought!

This is a (far) lateral disc herniation.


This next diagram shows the more usual pattern of a Postero-Lateral disc herniation, not to be confused with the the above (Far) Lateral disk protrusion. See how it gets a quite different nerve?

Pain and tingling in the leg, numbness and weakness. The Slump Test for sciatica  can be done at home to test for a pinched nerve.


Chronic disabling Low Back Pain

Low back pain is the most common and costly work related injury. The huge costs involved come from the relatively small number of people (but still a very large number of workers) who go on from an acute episode to chronic disability.

How can you know if this attack of lower lumbar back pain is going to go away, or become a nightmare?

A 2009 study from the University of Washington of 1885 workers with lumbar disc protrusion injuries, has come with some interesting facts:

Predictors of chronic disability

  1. The first and most important predicator is the patient's own report of how disabling and limiting the injury is.
  2. The second most important predicator was the patient's first health provider. If it was a chiropractor, the chances of the condition becoming chronic and disabling one year later was 5%. If it was a medical doctor, the chances were more than double - 12%.
  3. The number of pain sites. eg LBP + butt + posterior thigh + foot
  4. A 'very hectic' job.
  5. No offer of light work for a period.
  6. A previous injury with a month or longer off work.
  7. Reported: Spine vol 33: Early Predicators of Chronic Work Disability af a Back Injury by Turner et al.


CHIROPRACTIC HELP FROM THE COAL FACE


Mr Hanisch is a 45 year-old plumber who lifted a heavy washing machine up a narrow staircase. He felt something give in his back and the next morning had severe lower lumbar back pain. Turning in bed was extremely painful, he couldn't put his socks on, and a good smoker's morning cough gave him a vicious stab of pain in the back. Within a few days he felt pain radiating down the side of the leg and towards the great toe. (4 sites of pain: Lower back > side of thigh + side of calf + great toe)

Sitting and standing became very painful, and he walked with a limp because of the weakness that developed progressively in his foot. He tripped several times, aggravating the condition further, because his toe didn't lift normally in the swing phase of his gait.

By the time Mr Hanisch consulted me four months later, he had difficulty raising his great toe off the ground and the side of his lower leg and the top of foot felt numb - using a pinwheel, he said the prickle was 40% less. And the Medial Hamstring reflex was noticably diminished.

So far nothing unusual. This describes very typically an L4-L5 disc herniation. But the MRI was negative, and eventually he was sent back to work by the company doctor. Up to a point I can understand that: there is strong research showing that a man off work for more than six months is most unlikely ever to return. So, he was sent back to work. Only, he couldn't do his work as a plumber.

I admit to a hesitation. Often, one isn't absolutely sure which vertebra to manipulate. Either several are fixated, or none, or several are painful, and you are not absolutely sure. I wasn't sure: L5 was fixated, whereas it should have been L4.

For two weeks I made the wrong decision, following my neurology rather than the clinical examination, and adjusted L4. A mistake, and he didn't progress.

"To hell with it! The jammed up joint is L5, Mr Hanisch, I'm changing the treatment."

After the first adjustment of L5, he felt a slight bit of relief, and I could raise his leg a little higher at the next consultation, when I did Slump Test.

It was several months before the pain and weakness in his leg returned to normal, but after the rehab exercise program, he was able to return to work. A little wiser, he now gets help with heavy lifting.

An unexpected benefit was that he agreed to quit smoking. His doctor had often tried to persuade him with grave announcements about lung cancer and heart attacks, all of which he ignored. But when I told him his back was unlikely to heal with my treatment, and he would end up in surgery if he didn't quit, he made the noble decision. Stop Smoking Permanently ...

How do I know he had a (Far) lateral disc herniation? Frankly I don't. The MRI's of these Far Laterals are usually negative, and the only way to confirm it with is with a myelogram or surgery, both of which can have nasty side-effects. However, adjusting the level below that expected is what reduced the prolapsed disc...

Can chiropractic have nasty side-effects? Yes, indeed, though research consistently reveals that it is much less frequent, and the chance of going on to chronic disabiling pain with a condition like a Lateral Disc Herniation is 5/12 less likely that if you start with a medical doctor.

Have a moment of sympathy for your Chiropractor who is dealing with Lateral disc herniation. Surgeons too need a streak of stubborn boldness to get on with what needs to be done with the patient in severe pain, though his patients are under deep anaesthesia.



"Boldness be my friend."

- William Shakespeare


PREVENTION of LATERAL DISC HERNIATION

aka Lateral disc protrusion 

Each time you have an attack of acute low back pain, if it's associated with pain when you cough, sneeze or bear down on the toilet, you have likely lost some of the gel in the disc. This is even more so, if you go into the "leaning tower of Pisa" posture, or have pain in the leg. You are well on your way to having a 'flat tyre'.

Think prevention, like back exercises every morning, and some common sense when faced with heavy lifting if you want to avoid lateral disc herniation and the threat of lumbar spinal surgery. The 50 percent less pain rule is vital ...



"Walking is man's best medicine."

-Hippocrates, the Father of Medicine* (460-377 BC)

  • Hippocrates was an avid user of manipulation. We think of him as the Father of Chiropractor too, though...
  • The father of modern Chiropractic is D.D. Palmer. 
  • WALKING BENEFITS ...

IMPORTANT CONSIDERATIONS

If you have pain and tingling in the feet and legs...


LOWER BACK EXERCISES

Please remember that one size definitely doesn't fit all. Lumbar facet exercises are not entirely appropriate for a disc injury - don't pull both knees to the chest simulaneously.


Leg Length Inequality

Or in normal jargon, could you have a short leg? Leg length inequality research confirms that it causes not only hip and knee arthritis, but also lower lumbar back pain. It probably untimately is also one of the causes of lumbar stenosis, and probably lateral disc herniation, though is unresearhed. Leg length inequality and low back pain are now confirmed to be strongly associated. Not responding to Chiropractic? Has your Chiropractor considered a short leg?

Here is a leg length inequality CaseFile that might interest you.



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Interesting challenges of the day

1. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks she was 75 percent improved; no longer vomiting or falling. She's not enjoying the Brandt Daroff home exercises.

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has  two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?


Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

Your own unresolved problem. Pose a question

Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.


You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.

The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.