LUMBAR DISC PROTRUSION

(Keywords: LUMBAR DISC PROTRUSION, herniated lumbar discs, L4 lumbar spine, lower back pain, low back pain)

The terms lumbar disc protrusion, prolapse, herniated disc, bulging disk, slipped disc are all used very loosely and probably confusingly for you. All of them involve a bulging / tearing of the nucleus pulposis into the surrounding annulus fibrosis. The question is: has the tear gone deep enough to allow the bulge to pinch ther nerve?

Searching for something specific? Say, " FOODS THAT LOWER CHOLESTEROL NATURALLY ". Just type it in here...

Custom Search

At the CHIROPRACTIC COALFACE I find it useful to think of FIVE levels of a lumbar herniated disc. Disc and disk are used interchangeably.

1. Grade I: A bulge of the disc causing lower back pain with no leg pain
2. Grade II: A bulge of the disk causing low back pain and the first symptoms in the leg: tingling, pain, a numb feeling, but on testing there is no difference between the legs.
3. Grade III: Low back pain but now there is measurable difference on testing between the sensation in the legs. Prick the naughty leg and it's quite different to its compatriot in certain parts of the leg, more about that later. Now we are talking about the first signs of prolapse ...
4. Grade IV: Lower back pain, but now there is a feeling that the leg is becoming weak. You have difficulty standing on your toes, or you can't lift your big toe (which might make you trip) or your knee gives on the stairs. A progressing prolapse.
5. Grade V: This is the true, fully developed herniated disc. Often the lower back pain is less intense, but the leg is on fire.

Here's the trick: Take your Grade I lumbar disc protrusion (= mild slipped disc) seriously, do what it takes and wait long enough for the annulus fibrosis to heal (six weeks). Even though the pain may have ceased, recognise that it takes SIX WEEKS TO HEAL! Do the exercises faithfully.

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!

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 I slipped disc to turn into a Grade V surgical emergency.

Look after the pennies and pounds look after themselves. Look properly after a Grade I and you don't have to be concerned about Grade V LOWER BACK SURGERY ... Because, when the lower back pain stops, and the leg is on fire, the chances that conservative treatment like chiropractic can help you become much less.

Lumbar disc protrusion Casefile

Gradually, with the help of powerful antibiotics he got over the infection that he acquired in hospital ( IATROGENIC ILLNESS ) 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 night 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 stabs of 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 stab of pain in the back.

He reported that as a teenager he had two compression fractures in the lower back from a heavy rugby tackle.

ON EXAMINATION

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.

Two dilemmas

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:

1. Getting to the X-ray department over the weekend would be a nightmare, and would probably aggravate the condition.

2. There would be a delay of several hours in reducing the herniated lumbar disc.

3. The radiation exposure, not to be underestimated. According to a research paper published in the Lancet, a prostigious British medical journal, roughly 700 of the new cancer cases diagnosed each year in the UK are caused by medical X-rays. Did the benefits outweigh the risks? I decided not, but told him that if pain began in the leg, or he wasn't much improved with three days, then an X-ray would be mandatory.

4. The cost of an X-ray. They're not cheap.

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

1. Mr S was not to sit at all for three days.
2. He should ice his back at least twice a day. COLD HOT THERAPY ...



3. Forward bending was strictly verboten. He should go down on one knee if he needed to pick something off the floor.
4. He should immediately blow his nose if he felt a sneeze coming on.
5. He should do our three basic Lower back exercises for a lumbar disc protrusion every 15-30 minutes. They take only forty seconds.
6. He should spend three days on his bed*, doing the exercises, and at least every hour get up and walk around.
7. Pain is your friend. I recommended he take no pain killers.
8. He must listen to his back; it would tell him further what he could and couldn't do.

* 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.

PROGRESS

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 (Monday): Mr S was substantially better. He stood upright and the Slump Test was negative. Surprisingly, there was a right sacro-iliac 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 (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.

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.

DISCUSSION

Was this a misdiagnosis?

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.

Following instructions...

ATHEROSCLEROSIS SYMPTOMS LOW BACK PAIN - why smoking is so detrimental to the back too.

ANECDOTES

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

MONTHLY NEWSLETTER

BACK ISSUES