by Jason Schexnayder, PT, DPT, CMTPT
The “Dreaded” Disc Diagnoses
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, do these physical changes even matter? 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. 😉
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 in between each vertebra except between 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 both allows and restricts multi-directional movement and acts as a protective barrier around the nucleus. The nucleus allows for movement and stability of the spine. They act 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 basically impossible to break.
Bulge, herniation, degeneration…what’s the difference?
Unfortunately, the medical field doesn’t have a good consensus on terminology in regard to disc pathology classifications. Universities, doctors, chiropractors, therapists, etc. all have their own categories and grades for disc pathologies. Because of this, there’s a lot of confusion amongst patients and medical professionals on the topic and it even affects research on the subject. For this reason, we’ll keep it simple and narrow it down into 3 categories:
- Contained – commonly referred to as a bulge or protrusion. 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 or extrusion. The annulus has been damaged enough that the nucleus now extends out of the annulus. The nucleus stays intact but actually protrudes into the vertebral foramen.
- Sequestration – simply referred to as a sequestered disc or sequestration. The nucleus loses its integrity and has actually begun to leak further out of the annular tear. Part of the nucleus separates from itself. This is the most advanced form of a herniation.
Degeneration tends to occur throughout the spine. Bulges and herniations tend to occur in the cervical and lumbar regions, with the lumbar region typically being the most affected.
When deemed degenerative, the spine, either in its entirety or at particular segments, begins to lose its height. It does this for several reasons, one of which is thought to be because of dehydration of the discs. This loss of height can be accelerated depending on the type and frequency of stress placed on the spine as well as many other factors. But as you’ll see later on, this process occurs NORMALLY with time.
Each of the above conditions can “supposedly” place pressure on the nerve roots that lie within the vertebral foramen. Commonly, this is believed to be the source of spinal pain with these conditions. But recent research has shed more light on this theory, which we will discuss more later.
I need to get this off my chest…
- Don’t use the terms slipped or dislocated disc…EVER. Ok, that was harsh. Seriously though, the disc is too strong for anything like this to occur. So, please don’t use these terms. This type of speech biases 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 Spinal 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. In regard to 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.1 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 low back. Therefore, spine conditions attribute much more to medical cost, lost wages, lost productivity, etc. than these numbers show.
Imaging Doesn’t Tell the Entire Story
Pain is a multi-factorial, complex impairment. Physical change or damage to tissue doesn’t mean that you’ll experience pain. There are many studies that 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.2 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.”2 Below is a chart from that same study showing the prevalence of “abnormal findings” according to age. If you want more information on imaging, check out this blog I wrote previously.
Another consideration is that we know that the size of the bulge doesn’t necessarily matter. We also know that the disc bulge can heal and reduce in size over time, sometimes rapidly.
Of 368 patients with lumbar disc bulges, 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 disc bulge size was nearly IDENTICAL. So, disc bulge size wasn’t a predictor of poor outcomes with conservative management.
Similarly, a review of 11 studies involving a total of 587 people with lumbar disc herniations was performed. After conservative treatment, the disc bulges COMPLETELY reabsorbed in 66.6% of the patients.3 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, there are many other studies that 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.
If the Disc Can Heal & Size Doesn’t Matter…Then Why Do I 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 likely isn’t the PRIMARY cause of the 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 and 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, it 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 directly reduced people’s pain symptoms.4 So, 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.”5
Your next question should then be, “why do I hurt and other people with the same change to their spine not?” Unfortunately, there isn’t an answer to that yet. Maybe there is a threshold that’s met in regard to these inflammatory cells. Or maybe it’s a combination of many factors. Either way, we haven’t figured it out yet. 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 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.4 It occurs as a result of the inappropriate inflammatory response we mentioned above.
What do I do?!?
1. Conservative First!!!
Spinal surgery is common, especially here in the states. One study showed that spinal surgery was up to 5X HIGHER in developed countries, with the US having the highest rate.6 Seems like we’re quick to jump the gun on surgery. It must be because spinal surgery is successful at improving function, quality of life, and reducing the risk of future surgery…right? Ehh 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. Interestingly, in this same study, the 222 people that chose the conservative route faired the best of everyone. At an 8-year follow-up, only 56 (25%) ended up having surgery.7
After a recent low back injury, 50% of people recover in two weeks, 70% in 1 month, and 90% within 3 months.8 This is an example of the body’s ability to heal itself. Something I think goes unnoticed too often. The human body is very resilient and capable. It’s even more capable when you’re eating, drinking, sleeping, exercising, etc. appropriately.
However, these are just a few studies, and both only covering low back disorders. Plus, all research should be analyzed and considered carefully. But there are many other research studies that 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.
3. In My Opinion…
In regard to spinal conditions, if you have intractable pain, neurological deficit, or bowel or bladder dysfunction, surgery may be a good, early option. Sometimes it’s a very 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, then surgery 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. A good, conservative program makes your tissues more resilient and tends to reduce symptoms the majority of the time. If you have to have surgery, conservative treatment gives you time to mentally accept that you’re having surgery, which is vitally important. Therefore, conservative treatment, regardless of whether or not it reduces your pain, can help prepare both your mind and body for surgery and improve your outcome after surgery.
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 that is performed doesn’t “fix” what was actually 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, especially depending on the type of surgery. If you can avoid “the knife”, you can, and should, do everything you can to do so.
We now know that exercise can actually 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.9
That’s a lot of running! But it shows that certain types of activity could improve the quality of the disc. However, if you currently have back pain, you SHOULDN’T suddenly start running “no holds bar”. What it does mean is that you should consult a medical professional and try and gradually return to activity and exercise. Plus, exercise has a litany of other benefits outside of improving tissue quality. It can also reduce inflammation, which as we discussed, could be the primary cause of your “disc pain” in the first place.
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.”10 I would make an argument that certain high load activities, like regular weight-lifting and/or Olympic lifting, are beneficial but that’s beside the point. Again, the take-home point is that certain exercises may be beneficial for disc health.
The authors also mentioned that 8 hours/day of exercise may be optimal and 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 would consistently move fresh water and nutrients into and out of the disc and help maintain its overall health.
5. Adopt a Healthy Life
Eat healthily, get quality sleep, manage your stress, think positively, and so on. Practices like this are vital for a healthy life and one free of pain. This is especially true of diet and mental health. On top of a litany of benefits, adopting a healthier lifestyle could help you feel less pain or reduce your chance of ever experiencing it in the first place.
For some, it’s hard to live a healthy lifestyle. But life is hard in general so living a healthy one is doable. Plus, a QUALITY life should be a goal for everyone. No one wants to be the person waking up and living in agonizing pain or struggling to breathe because of a disease they could have prevented. These are the types of things an unhealthy lifestyle can lead to. So please consider adopting a healthier lifestyle so you don’t have to be one of those people.
- 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