How to Manage a Lumbar Herniated Discs

Nomenclature

Understanding the terminology is crucial in ensuring that communication between health professionals is exact and that patients have a clear understanding of their condition. The images at the end of the text from Fardon (2014), serve to illustrate these.

Normal disc - normal defines discs that are structurally normal. Figure 1.

Degenerative disc – Degenerative discs are included in a broad category that includes subcategories annular fissure, degeneration and herniation.  Annular fissures are separations between annular fibres or separations of annular fibres from their attachments to the vertebrae. Degeneration may also include any of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulus beyond the disc space, mucinous degeneration, fissuring, and intradiscal gas, osteophytes of the vertebral prophecies, defects, inflammatory changes, and sclerosis of the in plates.

Bulging - the presence of disc tissue extending beyond the edges of the ring throughout the circumference of the disc is caught bulging and is not considered a form of herniation.

Herniation – can be defined as a localised or focal displacement of disc material beyond the limits of the intervertebral disc space. Disc herniations can be sub classified into protrusions, extrusions and sequestrations.

Aetiology

Normal discs are inherently stable structures and even if we cut the outside of the disc (the annulus), the nucleus is intrinsically cohesive and resists herniation. Therefore it’s been hypothesised that disruption of the disc has to be preceded by an event which causes internal disruption of the disc. It has been theorized that the forces that occur with trauma or heavy lifting are sufficient to disrupt (fracture) the endplate of the vertebral. This endplate fracture is not symptomatic and may pass unnoticed and may even heal.  However this may set into action a series of events through an inflammatory response when the internal part of the disc is exposed outside the confines of a normal annulus that can lead to degeneration of the nucleus and the internal part of the annulus.

Management Options

Physiotherapy manual techniques, other modalities such as needling and exercises have no prospect of assisting this to resolve. Forced spinal manipulation is not recommended and may be dangerous. We limited in our management to teaching people how to manage their symptoms as best possible and in maintaining the patient’s fitness, lumbar spine strength and mobility, and educating the patient regarding the condition. This can take the form of some exercises, postural correction and correction of any poor movement patterns or habit which may be aggravating the condition.

Fortunately the symptoms from many disc herniations resolve and even the herniated disc material can be resorbed. One study looked at the probability that a lumbar herniated disc will resolved in a systematic review in 2015. The results indicated that the rate of spontaneous regression was found to be 96% for sequestration, 70 % for extrusion, 41% for protrusion and 13% for bulging.

It is important that patients who have these symptoms are monitored. Not all of these resolve and some regress and can even result in serious pathology, such as cauda equina compression that can lead to lower limb paralysis and or bowel/bladder dysfunction.

Chun-Chieh C, Tai-Yuan Chuang, Kwang-Hwa Chang, Chien-Hua Wu, Po-Wei Lin, Wen-Yen Hsu. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabiliation 2015, Vol 29(2) 184 – 195

Fardon D, Williams, A, Dohring, E, Lumbar disc nomenclature version 2.0 recommendations of the combined taskforces of the North American spine Society the American Society of spinal radiology and the American Society of neuroradiology. The spine Journal 14 (2004) 2525-2545