Lumbar disc bulges and back pain: Don’t Panic.
It s very common that when we meet clients who present with back pain that they report that they have a bulging disc and that they are under the impression this is the reason they have back pain. Unfortunately they are also under the impression that this will always be an issue and there is little that can be done for it
The purpose of this blog is to clear up what discs are and how they and and to hopefully put your mind at rest.
The most important thing to know is that the vast majority of people with disc related back pain can and do get better.
What the science tells us about disc bulges and back pain:
Here are the important messages that we get from the wealth of research on this topic:
- Disc bulges and herniations are capable of resolving without surgery.
- Effective treatment with exercise and advice is very successful in the short and long term with these issues.
- Most important is most of us have disc bulges and NO associated pain , that’s right NO PAIN.
- Disc bulges may actually just be a normal part of the aging process.
- The disc is capable of getting stronger over time with exercise.
What are the spinal discs?
So what are spinal discs and what do they do ? Well for a start what they DON’T do is slip or pop out of place !
There are 25 discs in the human spine;
- 7 in the cervical spine ,(or neck).
- 12 in the thoracic spine, ( or region of the ribcage).
- 5 Lumbar spine , ( low back).
- 1 Sacral , (between low back and pelvis).
They are quite ingenious feats of engineering and have multiple functions.
- They help allow the spine to be flexible without compromising its strength.
- They are also important shock absorbers.
- Provide a smoother surface for the adjacent vertebrae to move on relative to each other.
Anatomy of a disc
Discs are made up of three different regions, The major 2 areas that are most discussed are:
NUCLEUS PULOPSA: This is a thick viscous gel,(spine snot if you like). that is a real irritant if it comes in contact with nerve tissue. It is the most likely candidate in generating the pain response attributed to disc issues.
Actual pressure on a nerve seems not to be the main issue its contact with the nucleus.
ANNULUS FIBROSIS: This is fibrous/ cartilage like material arranged in concentric rings making them strong and resilient to forces applied to the spine.
In the outer third of the annulus of the disc is where we find a nerve supply and where there are nerves there is the potential for them to become sensitised.
ENDPLATE: On the top and bottom of the disc is the cartilage endplate which is responsible with binding the disc to the vertebrae. This is why discs can’t and don’t slip. They are also important with nutrition for the disc. Yup even discs need to be fed.
Do I have a disc problem in my back?
I’m going to make a few generalisations here but by and they hold true if your back pain has a discogenic cause;
- Tends to be more prevalent in under 55 age group.
- Mechanism of injury tends to be related to bending and twisting.
- They usually are worse with flexion based movements e.g. sitting and bending.
- Pain can refer down the leg in a specific pattern.
- Positions that make them feel better tend to be extension, so standing, walking or lying down may make the pain better.
How can discs cause back pain ?
The three most likely scenarios are :
Disc related back pain:
In the younger population, (under 55 years old), the disc can be a source of pain as a result of repeated bending and rotation especially if it involves extra load such as lifting a weight.
What is thought to happen is that the annulus develops small cracks or fissures extending towards the outer part of the disc where there are nerve fibres.
With repeated bending and twisting in some people the nucleus migrates through cracks in the annulus to the outer part of the disc. This then comes in contact with the nerve fibres and creates pain.
These types of disc related pain tend to respond really well to an exercise based treatment plan such as the Mckenzie protocol.
Disc herniation or protrusion:
Before we go any further the most important piece of information is that :
60% to 90% of lumbar disc herniations can be successfully treated without the need for surgery.
Herniations tend to be acute in nature and happen due to a specific incident. Again the mechanism is similar to disc related pain described above. However the symptoms tend to be more severe and restricting.
In this scenario the nucleus pulposa, (remember the spine snot ?), migrates to the back of the disc similar to the example above. However in this case it can bulge out of the constraint of the disc circumference.
It can then comes into contact with the nerves setting off a complex neuro-immune pain response…ouch. That’s sciatica to you and me .
This is what generates the symptoms of pain that can be very significant and extend down the leg to the foot. However it is possible that these can settle and the issue resolve with exercise, physio and time
Herniations are known to resolve without the need for surgery in many cases. This happens by
- retract back to their original position (more likely to occur in a bulge or focal protrusion).
- The herniation gets smaller through a dehydration process.
If the bulge or herniation is big enough it can cause weakness, numbness and altered neurological signs in the leg. It is these types of symptoms that we need a scan to see if specialist intervention or surgery is required.
Disc bulges and low back pain 
These are the most common finding of disc related changes in the low back. They look more like an overlapping of the disc on the vertebrae as opposed to a focal protrusion or herniation.
There is evidence that this may be part of the normal aging process of the disc and as such that is why they may not be the source of your back pain.
However as we get older a disc bulge along with other changes in our back such as facet joint spondylosis can create an extension based type back pain.
Bulging discs and MRI scans, they must be the cause of pain.
The graphic may be the most important information about disc related pain on this page.
This is not necessarily the case. Interestingly there are many of us wandering around living full lives, playing sport etc with no pain but on a scan they have evidence of disc bulges !
As we got older their incidence gets greater.
The significance of disc bulges and other findings on your scan results needs to be taken in context with your signs and symptoms of low back pain along with how your back pain started.
If your signs and symptoms can be related to the scan results then we can probably assume we have found a “player” in your pain or maybe even the culprit.
If the symptoms and scan don’t match up then maybe they may not be anything to worry about, but we can keep an eye on it. Even if they do match up with a disc related issue it just helps us get you on the right path and back to full health.
What should i do next if i have back pain related to a disc bulge or protrusion?
The key is always don’t panic and get assessed so you know what is really happening. The best thing to do is get assessed and put on the right path.
After that treatment is focused on the following key areas;
- Stay positive, its not the end of the road, just a bumpy bit of track. In fact some times disc related pain can respond very quickly to the right advice and movements.
- Positions of ease, especially in the acute phase to help reduce the pain. You may find that lying on your front, limiting sitting time helps ease the pain especially if your pain is made worse by bending.
- Walking has been shown to be of great value, especially brisk walking.
Discs love exercise: a fitter, stronger disc is a happier disc!
- McKenzie regime. a very effective protocol that is especially useful in the acute phase, can be very useful and encourages movement and self treatment.
- Core strength and disc related back pain: Getting your spine more flexion or compression tolerant with exercises to improve the fitness, strength and movement quality are key. Once the initial symptoms settle down its important to make sure we get on top of this aspect. This is a great start here .
- Get active again and address the underlying causes of why you have back pain. Not what structure may be aggravated and irritated.
In summary:
- Discs can be a source of pain but they can also be very responsive to treatment in both the short and long term.
- Don’t panic and love the disc, its a pretty cool wee thing.
Cheers
Dave
Chiu, C. C., Chuang, T. Y., Chang, K. H., Wu, C. H., Lin, P. W., & Hsu, W. Y. (2015). The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical rehabilitation, 29(2), 184-195.
https://www.raynersmale.com/blog/2016/6/14/the-bigger-the-bulge-the-better
https://www.raynersmale.com/blog/2016/6/21/spinal-degenerative-changes-are-a-natural-part-of-ageing