Oh, My Back!!!
Disc bulges, herniations, and degeneration…I’m sure most, if not all of you, have heard these terms at some point in your life. They are common diagnoses in the medical world. The question is, should you be as concerned about these changes as they sound?
We’ll attempt to tackle that question. Scientific articles will support the statements made in this blog. Of course, I’ll sprinkle in some personal opinions too. 😉
Basic spine anatomy
The spine is separated into the cervical, thoracic, lumbar, and sacral regions. There are 24 vertebrae, 23 intervertebral discs, a sacrum (tailbone), and a coccyx (small protrusion at the end of your tailbone). There is one disc between each vertebra except your head, 1st, and 2nd vertebrae.
The discs have two cartilaginous endplates, annulus fibrosus, and nucleus pulposus. The endplates assist in providing nutrition to the disc through diffusion. The annulus allows and restricts multi-directional movement and acts as a protective barrier around the nucleus. The nucleus provides movement and stability to the spine and acts as a fulcrum point for your vertebrae to move efficiently. Water and collagen primarily comprise the disc.
But don’t be fooled, the disc is an incredibly strong and resilient tissue. Think of each disc as a Chinese Finger Trap. Your fingers can move a lot while stuck in the trap, but they’re difficult to break.
Bulge, herniation, degeneration…what’s the difference?
Universities, doctors, chiropractors, therapists, etc. all have their categories and grades for disc pathologies without much cohesiveness. Because of this, there’s a lot of confusion among patients regarding pathology severity. However, we do have terminology that helps us classify disc-related pathology.
Contained – commonly referred to as a bulge. The outer layer (annulus) maintains its integrity. However, the inner layer (nucleus) has begun to put pressure on the annulus causing it to “bulge” into the vertebral foramen (fancy word for a hole).
This hole is where the spinal cord and the beginnings of your peripheral nerves are located, as well as small arteries and veins.
Non-contained – commonly referred to as a herniation. The nucleus extends into or out of the annulus by way of a fissure in the annulus (not a tear, a fissure). The nucleus protrudes into the vertebral foramen. There are generally 4 types of non-contained pathologies:
Protrusion
Extrusion
Sequestration – the nucleus loses its integrity and begins to leak further out of the annular tear. Part of the nucleus completely separates from itself. This is the most advanced form of a herniation.
Intra-vertebral Herniation or Schmorl’s Node - the herniated material extends into the end plate of the disc vertically.
Protrusions & extrusions are the most common among these 4.
Disc Degeneration.
Degeneration is quite broad and can include any or all of the following, and I quote: “desiccation, fibrosis, narrowing of the disc space, diffuse, bulging of the annulus beyond the disc space, fissuring (ie, annular fissures), mucinous degeneration of the annulus, intradiscal gas, osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the end plates.”¹
Degeneration tends to occur most often in the cervical and lumbar regions. When deemed degenerative, the spine, either in its entirety or at particular segments, begins to lose its height. This can occur for many reasons: age-related disc dehydration, genetics, physical activity levels, work type/frequency/intensity, other lifestyle factors, trauma, etc.
And, while “degenerative disc disease” sounds awful as a diagnosis, you’ll see later on, that this process occurs NORMALLY with time. Do me a favor, and try not to take everything Google tells you about a condition at face value.
I need to get this off my chest…
Don’t use the terms slipped or dislocated disc…EVER.
Ok, that was harsh.
Seriously though, these terms get tossed around by medical professionals, influencers, and the average Joe way too often. Our discs are too strong for anything like this to occur. So, please don’t use these terms. This type of speech can bias someone towards a train of thought about their condition that can affect their progress. Misinformation in the medical field runs rampant already and we don’t need to contribute to it.
The Spine Epidemic…
Pain in the cervical and lumbar regions makes up the majority of spine pain conditions. Spinal pain is such a large problem that it’s widely considered a GLOBAL EPIDEMIC. Regarding low back pain alone, a study showed that in 2001, office visits, hospital admissions, and common lumbar surgeries accounted for $20 BILLION of direct medical costs in the United States. This study EXCLUDED costs for medication and diagnostic tests.² Therefore, this amount was substantially higher. This same study also showed a large number of INDIRECT costs attributable to low back pain. It showed that 5% of American workers miss at least one workday per year due to low back pain.
Similarly, low back conditions make up the MAJORITY of the $50 BILLION lost due to decreased productivity from musculoskeletal disorders. Conditions of the cervical spine aren’t as well studied either, so these numbers only represent the United States and conditions involving the lower back. Therefore, spine conditions attribute much more to medical costs, lost wages, lost productivity, etc. than these numbers show.
Imaging doesn’t tell the entire story.
Pain is a multi-factorial, complex experience. Despite popular belief, physical change or damage to tissue doesn’t mean that you’ll experience pain. Many studies use imaging to show that the majority of us have some type of physical change to our tissues but don’t experience symptoms.
In fact, a study of 3,110 people showed that disc degeneration increased from 37 – 96% from your 20’s to your 80’s. Disc bulges increased from 30 – 84% for the same age groups.³ Several other disc pathologies were present in young individuals and prevalence increased with age. However, this study was on ASYMPTOMATIC patients. That means even though A LOT of people had abnormal imaging findings (even young people), they had no pain or disability.
As I said, image findings provide information but they DON’T tell the entire story. The researchers went on to say, “Our study suggests that imaging findings of degenerative changes such as disc degeneration, disc signal loss, disc height loss, disc protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”³
If you want more information on imaging, check out this blog I wrote previously.
Chart from the study mentioned above showing the prevalence of “abnormal findings” according to age. NONE of these people have pain or disability.
Herniation Size & Reabsorption
Another consideration is that herniation size doesn’t necessarily relate to pain severity. We also know that the herniation can heal and reduce in size over time, sometimes rapidly.
Of 368 patients with lumbar disc herniations, only 32 required surgery due to poor outcomes after 6 weeks of conservative treatment. When comparing the 32 that required surgery to the ones that didn’t, the size was nearly IDENTICAL. So, herniation size wasn’t a predictor of poor outcomes with conservative management.⁴
Similarly, a review of 11 studies involving a total of 587 people with lumbar disc herniations was performed. After conservative treatment, the herniations COMPLETELY reabsorbed in 66.6% of the patients.⁴ This means that the disc reduced in size back to its original state with time and conservative treatment. This meta-analysis didn’t have any randomized controlled trials (high level of research) so results should be perceived with caution. However, many other studies show discs can reabsorb in time. There are even more studies that show conservative treatment should be the first course of action due to favorable results.
So, why does it hurt?
Unfortunately, we don’t know the exact answer to that. This is the case for most conditions because of the complexity of pain. However, the physical presence of a disc abnormality might not be the PRIMARY cause of pain. That doesn’t mean the physical change of the disc isn’t important, it just means it too, doesn’t tell the entire story.
Inflammatory & Immune Response
Over the last several years, we’ve learned that there is a complex, abnormal inflammatory and immune response occurring at the site of the disc. Normally, your body does a great job of healing itself and reducing pain in response to injury. Believe it or not, most of the time, inflammation is a good thing. However, at times, and for UNKNOWN reasons, your body responds inappropriately and causes more problems.
A research review on the cellular processes of painful disc herniations and degeneration covered this very topic. It revealed that inflammatory cells accumulate at the site of impairment (our blog on obesity covered some of these cells). This makes it difficult for the disc to heal properly, and, more importantly, can lead to increased pain symptoms (allodynia and hyperalgesia). What’s interesting is that this study referenced research that focused on treating some of these cells directly. Without addressing the physical change in the disc, treating these cells reduced people’s pain symptoms.⁵ Therefore, addressing the inflammatory cells themselves and NOT the actual physical change in the disc, reduced symptoms.
The authors of a similar study went as far as to say, “Still, it is exactly an inflammatory response that causes a harmful effect on the adjacent nerve roots, causing pain.” They also made the statement, “Different forms of NON-SURGICAL treatments should be EXHAUSTED before considering surgery in acute stages of LDH (lumbar disc herniation) unless conservative treatment is contraindicated for reasons such as neurological deficit and intolerable pain despite administration of adequate pain medications.”⁶
Your next question should then be, “Why do I hurt and other people don’t?” Unfortunately, there isn’t an answer to that yet. More than likely, it’s a combination of 1000’s of factors. It’s not the answer I want to give you, but it’s the honest one.
Nerves and Blood Vessels
Normally, the inner disc ISN’T innervated by nerves and contains few blood vessels. However, the same study from above showed the ingrowth of nerves and blood vessels into the inner disc. This is thought to contribute to the pain cycle. This ingrowth can also contribute to cell death of the dorsal root ganglion (DRG), which is an essential area of the spinal cord that’s involved in pain control.⁶ It occurs as a result of the inappropriate inflammatory response we mentioned above.
What do I do?!?
Conservative First!!!
Spinal surgery is common, especially here in the States. Spinal surgery is 5X MORE LIKELY in developed countries, with the US having the highest rate.⁷ It seems like we’re quick to jump the gun on surgery. It must be because spinal surgery improves function, quality of life, and the risk of future surgery…right? Eh, not necessarily.
Of 1224 people with disc herniations, 810 underwent surgery. Some CHOSE surgery while others were RANDOMLY ASSIGNED to have surgery. 119 (15%) ended up having a re-operation. Of those 119 people, 40% had a re-operation within 1 year and 55% had a re-operation within 2 years. Many of these re-operations were because of a disc herniation occurring at the SAME LEVEL as their original condition. The surgery was meant to “fix” this problem in the first place, yet these people had a recurrence within 1-2 years (that sucks!!!).
Interestingly, in this same study, the 222 people who chose the conservative route faired the best of everyone. At an 8-year follow-up, 56 (25%) had surgery.⁸
Give It Time
After a recent low back injury, 50% of people recover in two weeks, 70% in 1 month, and 90% within 3 months.⁹ This is an example of the body’s ability to heal itself. Something I think goes unappreciated too often. The human body is resilient and capable. It’s even more capable when you’re consistently eating, drinking, sleeping, exercising, etc. well.
These are just a few studies, and both only cover lower back conditions. Plus, all research should be analyzed and critiqued carefully. However, many other research studies show similar results. In general, people who undergo surgery tend to have a higher risk for another surgery. People who choose to follow an appropriate conservative treatment route tend to do well in the long run and avoid surgery more often.
In My Opinion…
Regarding spinal conditions, if you have intractable pain, neurological deficit, or bowel or bladder dysfunction, surgery MIGHT be a good, early option. Sometimes, it’s a necessary option. But, the MAJORITY of the time, it SHOULDN’T be the FIRST option. Surgery isn’t going anywhere. If conservative treatment doesn’t work, the surgeon will be waiting for you at the end. And, studies consistently show that people who physically prepare their bodies and mind for surgery almost always do better than those who don’t.
If you have to have surgery, conservative treatment gives you time to mentally accept that you’re having surgery, which is a vital component that isn’t talked about enough. Also, this is no different than an athlete training for their sport. Training reduces their injury risk and improves their performance. Conservative care before surgery does the same. It prepares you physically and mentally for the surgery to come. Therefore, conservative treatment, regardless of whether or not it reduces your pain, should be the first choice of care.
Also, many people believe surgery will “fix” their “problem” and that recovery will be a walk in the park. Ask most people who have had surgery, and they’ll tell you a different story. At times, the surgery performed doesn’t “fix” the CAUSE of pain. Remember, physical change in a tissue isn’t necessarily the source of your pain. Also, the road to recovery for most people will be a long, painful road. If you can avoid “the knife”, you can, and should, do everything you can to do so.
Exercise
We now know that exercise can improve the quality of the disc. Moderate and long-distance runners have been shown to have increased disc size compared to HEALTHY people who are INACTIVE. However, the long-distance runners (50+ km a week for 5 years) demonstrated the most significant, positive change in their disc. The difference between them and the joggers (20-40 km for 5 years) wasn’t statistically significant though, so running moderate distances appears to work just as well.¹⁰
That’s a lot of running! However, it shows that certain types of activity could improve the quality of the disc. However, if you have back pain, you SHOULDN’T suddenly start running “no holds bar”. You should consult a medical professional who can help guide you back to an active life. Plus, exercise has a litany of other benefits outside of improving tissue quality.
A narrative review of the literature stated, “Overall, these studies tell us that a lifestyle of a moderate amount of physical activity…is likely to be more conducive to good IVD (disc) health.”¹¹ I would make an argument that certain high-load activities, like regular weight-lifting and/or power exercises like sprinting/jumping/etc., are beneficial. But, that’s beside the point. Again, the take-home is that exercise is beneficial for disc health.
The authors also mentioned that an EXERCISE-REST-EXERCISE protocol may be best. This makes sense as the discs fill up with water and nutrients while resting. Then, water and nutrients are flushed out when active. This exercise-rest-exercise regiment could create a “pump” effect that consistently moves nutrients into and out of the disc and helps maintain its overall health.
Adopt a Healthy Lifestyle
Eat healthily, get quality sleep, manage your stress, think positively, and so on. Practices like this are vital for a high-quality life. On top of that, adopting a healthier lifestyle could help you feel less pain or reduce your chance of ever experiencing it in the first place.
For many, it’s hard to do these things consistently well. But, a HIGH-QUALITY life should be a goal for everyone. No one wants to be the person waking up or living in pain or struggling to breathe because of a disease or injury they could have prevented. These are the types of things an unhealthy lifestyle can lead to.
References:
Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88 Suppl 2:21-24. doi:10.2106/JBJS.E.01273
Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
Zhong M, Liu JT, Jiang H, et al. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45-E52.
Risbud MV, Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol. 2014;10(1):44-56. doi:10.1038/nrrheum.2013.160
Cunha C, Silva AJ, Pereira P, Vaz R, Gonçalves RM, Barbosa MA. The inflammatory response in the regression of lumbar disc herniation. Arthritis Res Ther. 2018;20(1):251. Published 2018 Nov 6. doi:10.1186/s13075-018-1743-4
Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G. An international comparison of back surgery rates. Spine (Phila Pa 1976). 1994;19(11):1201-1206. doi:10.1097/00007632-199405310-00001
Leven D, Passias PG, Errico TJ, et al. Risk Factors for Reoperation in Patients Treated Surgically for Intervertebral Disc Herniation: A Subanalysis of Eight-Year SPORT Data. J Bone Joint Surg Am. 2015;97(16):1316-1325. doi:10.2106/JBJS.N.01287
Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353-371. doi:10.1016/j.ncl.2007.01.004
Belavý DL, Quittner MJ, Ridgers N, Ling Y, Connell D, Rantalainen T. Running exercise strengthens the intervertebral disc. Sci Rep. 2017;7:45975. Published 2017 Apr 19. doi:10.1038/srep45975
Belavý DL, Albracht K, Bruggemann GP, Vergroesen PP, van Dieën JH. Can Exercise Positively Influence the Intervertebral Disc?. Sports Med. 2016;46(4):473-485. doi:10.1007/s40279-015-0444-2
Disc Classification Images: Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014;14(11):2525-2545. doi:10.1016/j.spinee.2014.04.022
