Lower back pain (LBP) is one of the most prevalent presenting pathologies worldwide. Approximately 80% of the world’s population experience an incident at least once in their life with lumbar disc herniations showing an incidence rate of 5 to 20 cases per 1000 adults annually. Disc herniations are most prevalent in adults from their 30s to 50s and more common in males to females with a 2 to 1 ratio (1). From 2015 to 2018, there were 43,185 hospital admissions for lumbar spinal decompression surgeries to treat severe lower back pain with radicular symptoms in Australia – this represents 74 hospitalisations per 100,000 people over the age of 18 years (2).
So, let’s bust 4 common MYTHS surrounding lumbar disc herniations:
Myth 1: Disc just "slip out" of place:
Intervertebral discs are like spongy cushions between the bony vertebrae of our spine. Discs consists of an outer elastic shell known as the ‘annulus fibrosis’ and an inner gel-like substance which makes the ‘nucleus pulposus’ – these structures are very strong, resilient and are further supported by thick ligamentous tissue creating a durable support system that provides spinal stability, shock absorption, and allow movement of the spine. “Slipping a disc” is next to impossible. The old comparison between disc injuries and a jelly donut that bursts is so far from the truth and very harmful to a patient's outlook on their halth.
Signs and symptoms of a lumbar disc injury depends on its mechanism of injury,
location, and severity – these may include:
-Limited lumbar flexion or bending
-Increased pain with repetitive bending and/or prolonged sitting
-Altered sensation such as pins & needles and/or numbness
-Weakness of lumbosacral nerve root distributions
-Increased pain with coughing and/or sneezing
-Radicular pain of the lower limbs (3)
Disc herniations are the displacement of the nucleus pulposus and can be pathologically classified into 4 separate grades:
Bulging – compression of the disc in every direction with small fissures present in the annulus fibrosus but no interruption to the outer limit of the annulus.
Protrusion – bulging of the nucleus pulposus to the annulus without interruption to the outer part of the fibre ring.
Extrusion – complete interruption of the annulus fibrosis with portions of the nucleus pulposus bulging outside of the fibre ring.
Sequestration – portions of the nucleus pulposus and annulus fibrosus detach from the disc (4).
Myth 2: "Moving will injure my back more, I need to rest.”
How do we treat it and how long will it take?
Disc pathologies can be quite painful and restrict activities of daily living. However, majority of symptomatic and painful disc herniations will heal and resolve within 2 to 12 weeks after injury. Non-operative interventions are the first line of treatment with 90% of cases resolving within 6 weeks – non-operative treatment can include physiotherapy, load management, activity modification, non-steroidal anti-inflammatory drugs, and epidural steroid injections (5).
Physiotherapy can involve many forms of conservative treatments such as specific exercise prescription, biomechanical correction, taping, dry needling, McKenzie therapy, joint mobilisation, and massage therapy. For the best outcome during an individual’s rehabilitation, it is recommended for the patient to remain active within their pain tolerance. Modern evidence has proven that bed rest for longer than 2 days can be harmful to the injured person due to loss of muscle and strength, reduced mobility and limited activity deconditioning the
patient.
Weber et al found that 70% of patients suffering lumbar disc herniated sciatica reported significantly reduced pain within 4 weeks of conservative treatment (6).
Myth 3: “An MRI scan will show exactly where my pain is coming from.”
How to diagnose your lower back pain.
A detailed patient interview and physical examination by your Physiotherapist is generally enough to diagnose lumbar disc herniations. If your physiotherapist recommends further investigations, Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans may be necessary. However, keep in mind that in many cases individuals with herniated discs confirmed via MRI and are asymptomatic and do not cause the person any pain or dysfunction. Studies have found an increase in prevalence of degenerative spinal pathologies with age as seen in the table below:
Myth 4: “Surgery is the only treatment option. “
Who should have surgery?
Early indications or “red flags” for immediate surgical intervention include progressive and significant loss of lower limb strength, sensation, reflexes, or any symptoms of Cauda Equina Syndrome – a dysfunction of the lumbosacral nerve roots of the cauda equina. These signs and symptoms effect bladder and bowel function and may include urinary retention, urinary and/or fecal incontinence, “saddle anesthesia” and sexual dysfunction.
As stated above, 90% of cases involving lumbar disc herniations are resolved with conservative treatment within 6 weeks. In more severe cases involving the signs and symptoms as mentioned above, a policy by the International Society for the Advancement of Spine Surgery clinically indicates surgery for those who fail conservative treatment – these indications are:
- Clinical signs and symptoms of lumbar disc herniations
- Imaging confirmation of lumbar disc herniation consistent with clinical findings
- Failure to improve after six weeks of conservative care (5)
If surgery is not clinically suggested, if it important to discuss with your physiotherapist a rehabilitation plan going forward. Studies have indicated surgery may provide earlier pain relief in the short term (3 weeks) in comparison to conservative treatment but show similar improvements and no clinical difference at mid-term (3 months) and long-term (12 months) follow up in regard to neurogenic symptoms, physical function and quality of life.
Key takeaway messages:
Signs, symptoms, and red flags of disc herniations as above.
Non-operative interventions are the first line of treatment for lower back pain – minimal bed rest and activity modification is recommended best practice in the modern day.
A detailed patient interview and physical assessment by a physiotherapist should be sufficient to diagnose a disc herniation.
Don’t rush for imaging, they don’t always show where you pain is coming from – disc herniations are present in MRI and CT imaging in many asymptomatic patients.
Surgery may be indicated in the presence of “red flags” or failure of conservative treatment, however, surgical and conservative treatments show similar improvements in mid-term and long-term follow ups.
References
1. Al Qaraghli MI, De Jesus O. Lumbar Disc Herniation. [Updated 2022 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560878/
2. 3.3 Lumbar spine surgery hospital admissions 18 years and over Context. (n.d.). Retrieved November 23, 2022, from https://www.safetyandquality.gov.au/sites/default/files/migrated/SAQ201_04_Chapter3_v6_FILM_tagged_merged_3-3.pdf
3. Back pain – disc problems. (2012). Vic.gov.au. https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/back-pain-disc-problems
4. Lachman, D. (2015). Analysis of the clinical picture in patients with osteoarthritis of the spine depending on the type and severity of lesions on magnetic resonance imaging. Reumatologia/Rheumatology, 4, 186–191. https://doi.org/10.5114/reum.2015.53995
5. Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc Herniation. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2022. PMID: 28722852.
6. Yoon, W. W., & Koch, J. (2021). Herniated discs: when is surgery necessary? EFORT Open Reviews, 6(6), 526–530. https://doi.org/10.1302/2058-5241.6.210020
7. Hall, A. M., Aubrey-Bassler, K., Thorne, B., & Maher, C. G. (2021). Do not routinely offer imaging for uncomplicated low back pain. BMJ, n291. https://doi.org/10.1136/bmj.n291
8. Gugliotta, M., da Costa, B. R., Dabis, E., Theiler, R., Jüni, P., Reichenbach, S., Landolt, H., & Hasler, P. (2016). Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open, 6(12), e012938. https://doi.org/10.1136/bmjopen-2016-012938