Keywords; lumbar disc protrusion, lower back and leg pain, femoral nerve, help for sciatica pain.
The terms prolapse, herniation, a bulge and slipped disc are used very loosely and probably confusingly for you. All of them involve a a degree of damage to the annulus fibrosis and protrusion of the nucleus pulposis beyond its normal confines.
The question is, has the tear gone deep enough to allow the bulge to pinch the nerve?
That could the be sciatic or femoral nerves; the former emerges from the lowermost lumbar spine and the latter somewhat higher.
Here's the trick. Take your grade one lumbar protrusion, also known as a mild slipped disc, seriously; do what it takes and wait long enough for the annulus fibrosis to heal; that's six weeks. Even though the pain may have ceased, recognise that it takes, yes, at least one and half months to heal.
Don't move the grand piano. Don't go back to gym yet, or at least be very careful. Try not to sit more than you need to. Don't go on a long journey. Bend very carefully, and better still go down on one knee to pick up your shoes off the floor. And lastly it makes no sense to disguise the pain with anti inflammatory pills, analgesics or muscle relaxants.
Do the exercises faithfully. Start walking daily, and better still swimming too. Do use the ice and heat when you have the occasional less than optimal day.
Lumbar surgery is a huge cost to medical insurance and whilst it's sometimes necessary, often it comes about when a person, not you, of course, hurts their back but returns to normal activities before it's healed.
Do all this, then you, and your chiropractor will be happy. The only person who might be unhappy is the neuro or orthopaedic surgeon. They've just lost out on their annual skiing holiday in the Swiss Alps that you were about to sponsor!
At the CHIROPRACTIC COALFACE I find it useful to think of FIVE levels of a lumbar herniated disc. Disc and disk are used interchangeably. More traditionally, it's considered that there are four levels of slipped disc.
Obviously I'm speaking in jest. No doctor, especially highly qualified surgical specialists are worrying about where their next holiday is coming from. Nor do they want your grade one slipped disc to turn into a level five surgical emergency.
Look after the pennies and the pounds look after themselves. Care properly for a small lumbar disc protrusion and you don't have to be concerned about a grade five and lower back surgery. Because, when the back pain stops, and the leg is on fire, the chances that conservative treatment like chiropractic can help you become much less.
This lumbar disc protrusion casefile will make interesting reading.
Mr S, a 38 year old man consulted me three weeks ago with severe left low back pain, with no radiation to the leg; thus a grade one.
Nine months ago he had a knee operation that went sour; in hospital he got a serious infection in the knee during the operation, and for five months he had difficulty walking and developed a marked limp.
Gradually, with the help of powerful antibiotics he got over the infection that he acquired in hospital and was able to start exercising again. In the interim he had put on quite a lot of weight. He started to jog gently and even playing tennis.
Then, two weeks ago, after a game of tennis he developed nagging lower back pain, but it passed over within 24 hours with the help of anti inflammatory pills.
Then, the evening before his first consultation, now three weeks ago, he again played tennis. That night he developed severe lower back pain. He couldn't sleep, and every move in bed caused sharp pain in the back. In the morning he felt completely disabled and his back felt like jelly. His wife had to put his shoes and socks on; every movement causing sharp stabs of pain in the lower back. A sneeze gave him a very disabling sharp stabs of pain.
He reported that as a teenager he had two compression fractures in the lower back from a heavy rugby tackle.
Mr S stood in a "stuck forward" posture, known as "an antalgia", a posture that the lower back adopts to protect it from further injury. Usually an antalgia is a sign of herniated lumbar discs but a facet syndrome can also cause it, mainly in the older person.
The Valsalva test was positive, strongly suggestive of a lumbar disc protrusion. Bearing down gave him sharp low back pain.
Forward flexion was very guarded, invoking the "jello-like" feeling in his back. As though it was suddenly going to collapse. Lumbar extension, and side bending bilaterally were also very painful.
The Slump test for sciatica was extremely painful when raising the left leg, and slightly painful when raising the right leg, but only in the back. The Straight Leg raise test of Lasegue was extremely painful at 15 degrees on the left, again fortunately only lower back pain.
There was a L4 lumbar spine fixation on motion palpation.
There were no abnormal neurological findings.
The clearcut diagnosis was a small lumbar disc protrusion, Grade I, with no involvement of the sciatic nerve at that stage.
To X-ray, or not to X-ray, that was the question. The reasons in favour of an X-ray were the old compression fractures and the very severe pain. The reasons against were:
The second dilemma was a holiday booked that would involve eight hours in the car. I told him and his wife that it was highly likely they would have to call off their holiday.
HOME INSTRUCTIONS for a Lumbar Disc protrusion
* Bed rest is controversial. There is much research confirming that bed rest alone aggravates a lumbar disc protrusion. However, if the patient is not to sit, and can't stand for any length of time... he's between the devil and the deep blue sea.
My compromise is three days' bed rest with regular exercises and getting up hourly to walk about.
First treatment (Sunday): I made sure he could do the basic three exercises correctly. Whilst he could get them off the website, there's no substitute for a experienced professional showing the patient EXACTLY how they should be done. Acute pain is frightening, and many patients are anxious about the exercises. The movement helps to bring nutrients to the damaged tissue, fresh oxygen, and removal of the waste inflammatory products that would be building up.
Soft tissue massage whilst lying on his side. Lying prone on the belly often increases acute low back pain.
A gentle side-posture manipulation, with the painful side down, using a standard spinous-push manoeuvre. We both felt and heard the offending bulging nucleus pulposis reduce back to its correct place. The adjustment (manipulation) was not painful.
Second treatment on Monday: Mr S was substantially better. He stood upright and the slump test was negative. Surprisingly, there was a right sacroiliac fixation. I used the standard Thompson drop protocol, with no side posture manipulation. I carefully outlined the 50 percent less pain rule to him, warning him that a set back would almost certainly mean radiating pain down the leg.
Third treatment on Tuesday; Mr S had almost no pain. He's taken everything very seriously; he wants to go on holiday despite a potentially devastasting lumbar disc protrusion. His mother has had a two back operations so he knows what it's about.
I repeated the side posture manipulation,
again lying only on the painful side down. We both felt a much smaller
click, probably from the facet joint. I then did a supine AP drop
technique on the fixated right sacroiliac joint.
I allowed him to go on holiday provided he make room in his suitcase for
the icepack; probably not necessary, but just in case, and the
exercises, and provided he could lie down in the back of their SUV
whilst she who must be obeyed drove. Have you got one of them at home?
I gave him a more difficult exercise to strengthen the core muscles, to be done cautiously if his back would allow it.
Fourth treatment (10 days later): Mr S had no pain. He reported that after the long drive his back was a little tender, no real pain, and for two to three days he was very careful on the beach, doing backstroke regularly in the pool. Then everything stabilised. He drove most of the way home with minimal discomfort.
Range of motion was full and free, there was still a mild fixation of L4 lumbar spine. We repeated the gentle side-posture manoeuvre. I gave him a new, more difficult exercise, and asked him to return in three weeks.
Was this a misdiagnosis?
Critics would say that there is absolutely no possibility that a lumbar disc protrusion could have responded so quickly.
My reply is that the pathognomonic signs of a lumbar disc protrusion were clearcut: pain on forward bending, the antalgic posture, the extreme disability and "jelly-like" feeling, pain with a Valsalva and a very strongly positive Lasegue and Slump tests.
Prompt reduction of the protrusion
Our chiropractic experience is that if herniated lumbar discs are reduced with twenty-four hours, before swelling and inflammatory products are produced (and preferably within twelve hours) an uncomplicated lumbar disc protrusion will often respond very quickly to chiropractic care.
If that critical first 24 hour period is missed and he waited three days, there was a strong possibility that leg pain would have started. Wait three months, messing about with pills... and he has backache for life.
Mr S was a model patient. He followed my instructions to the letter, and benefitted accordingly. So many people wish to continue with their normal life, especially sitting, not stopping smoking, and bear the consequences. Uncomplicated lumbar disc protrusions, neglected, often proceeds to the full blown herniated lumbar discs, aka a lumbar disc prolapse.
The L4-L5 disc would classically produce pain and tingling down the side of the leg and stretching over to the great toe. The medial hamstring reflex would likely diminish, there would initially be hypER sensitivity (increased) in the web between the great and second toes, later hypO (numbness) and he might develop difficulty lifting his great toe.
If raising your left leg in the so-called Slump Test gives you more right lower back pain, it's both a good and bad sign.
Good? Because the crossed sign means you have postero medial slipped disk which are usually easier to manage with chiropractic adjustments if there is no significant leg pain.
Bad? Because a higher percentage of patients with the medial disc end up under the knife. Read about it at the link just above.
One particularly nasty sign: if raising the left leg as in the graphic above, gives you RIGHT leg pain, then it's going to be difficult.
The femoral nerve emerges from higher in the lumbar spine and supplies predominantly the front of the thigh and the inner lower leg; it is the motor nerve to the quadriceps muscle. Weakness causes a profound limp.
Femoral nerve lesions tend to occur more often in the older person.
Always treat anecdotes like this on the web with a certain amount of skepticism. Even by my standards, Mr S responded remarkably quickly. Anecdotes are not scientifically proven remedies.
But the underlying principles are valid: take a small problem seriously, exercise is always vital, (the right exercises), reduced sitting is usually necessary and ice makes a good anti inflammatory and painkiller.
And get the bulging disc reduced as soon as possible, no matter how much pain you are in. By an experienced chiropractor preferably, but there I am obviously biased! By some local doctor you trust.
USEFUL LINKS @ LUMBAR DISC PROTRUSION
Bending and twisting
Lower back and leg pain
Lumbar facet syndrome