Lumbar Bulging Disc
What is a Lumbar Bulging Disc?
A spinal disc bulge, or a “slipped disc”, is a common cause of low back pain and is a less severe case of low back pain compared to lumbar disc herniation. The spine is made up of a series of vertebrae-disc-vertebrae segments with the disc generally acting to provide some cushion and maintain alignment of the joints. Each disc is made up of a gel-like center with fibrous outer rings. The discs are similar to a balloon filled with air, if one side is squeezed, the air moves to the other side. When the discs are compressed under high load (like lifting with a load on the front side of the body) or compressed frequently (such as sitting all day) the fibrous rings are stressed and have the potential to break down. This can lead to ballooning of the disc from its original position causing infringement onto a nerve root which can compress the nerve root and/or spinal cord. The compression or irritation of the nerve root leads to localized low back pain with associated leg pain in the distribution of the particular muscles that are innervated by that nerve root. The leg pain felt in a disc bulge case typically does not radiate past the knee. If pain radiates past the knee, a more serious condition called a disc herniation may be present (see alternate page).
A lumbar disc bulge is most commonly treated with Flexion Distraction therapy or spinal distraction. Our chiropractors use a special table designed specifically to decompress the spine and take the pressure off of the lumbar disc helping to decrease compression of the irritated nerve. By taking the pressure off of the nerve in the low back, your leg symptoms will decrease and the local back pain will dissipate. The therapy is usually coupled with using Active Release Technique (ART) on the muscles of the lower back, hip, and leg to further decrease the compression on the sciatic nerve or pinched nerve. Using the electric muscle stimulation can further help to decrease the nerve pain and help to temporarily block the bodies ability to sense the pain, like a natural ibuprofen. We also integrate a combination of chiropractic care, physical therapy, and functional rehab that will help get you out of pain and back to enjoying the activities you love-faster. Low back pain relief can typically be seen in just a few visits.
What Will Lumbar Disc Bulge Look and Feel Like?
The clinical presentation is dependent upon the degree of neurologic involvement - the level of compression occurring at the nerve root. Asymptomatic disc bulges are present in 20-36% of the adult population. Lesions without mechanical compression may produce a chemical radiculopathy consisting of only local low back discomfort and pain, or sensory disturbances that radiate into the buttock or lower extremity, usually above the knee.
The following factors have a predictive accuracy of 92.3% for chemical radiculopathy in lumbar disc bulge patients:
Back pain < 5/10
Symptoms worse the next day after injury
Lumbar flexion range between 0 and 30°
Positive clinical inflammation score (at least 3 of the following: constant symptoms, morning pain/stiffness lasting over one hour, short walking not easing symptoms, significant night symptoms)
Mechanical compression of a nerve root can produce all of the earlier-mentioned sensory disturbances plus motor (strength) deficits and diminished reflexes. Radicular pain is described as sharp and superficial, sometimes accompanied by tingling and numbness. One should be alert for the presence of cauda equina symptoms (saddle numbness/ paresthesia, loss of bowel/bladder function, bilateral weakness, impotence, etc.). Cauda equina syndrome is present in approximately one in one thousand low back pain patients who present to primary care offices. Cauda equina patients who progress to urinary retention and incontinence will often have long-term urinary sphincter impairment, even after surgery and need to seek medical attention immediately.
Research by Nachemson has shown that intradiscal pressures vary based upon body position (sitting produces the highest posture followed by standing which is followed by lying side posture and finally lying supine produces the least). Holding weighted objects or flexing forward increases intradiscal pressure and often subsequent pain and should be avoiding in the early phase of injury. It follows that most disc lesions fit into the directional preference category of “extension biased”, meaning that they are alleviated by extension positions including standing, walking or lying on your stomach, but are aggravated by flexed positions like sitting, driving or bending. “Flexion biased” disc problems are rare, however are alleviated by sitting, bending or squatting and are provoked by extension. One should discontinue any movement or activity that causes any sign of peripheralization - the phenomenon when pain emanating from the spine, although not necessarily felt in it, spreads further down the limb. Some degree of sensation loss is present in up to 80% of patients suffering from lumbar disc-related radicular symptoms.
Evidence of progressive neurologic deficit warrants surgical consultation, specifically if there are motor/strength deficits that persist after regular and consistent treatment.
How Do We Treat Lumbar Disc Bulge?
Disc bulge with radiculopathy may be successfully managed via conservative treatment. In fact, the majority of disc bulges will reduce over time with non-surgical care. One very large study reported that 97% of all symptomatic bulges will not require surgery. The size of the bulge has no predictive value with regard to the failure of conservative management or likelihood of requiring surgery. Large “herniations” trigger a significant inflammatory response and generally regress more quickly when compared to contained “bulges” that do not benefit from reabsorption. Associated motor deficits improve over time for both surgical and conservatively treated patients.
The goal of conservative management should be to centralize symptoms (move symptoms back towards the source of pain in the low back), reduce pain & inflammation, decrease mechanical compression with improved body mechanics and improve functional core stability. Directional preference (extension versus flexion) is an important point of differentiation when selecting treatment plans, however will typically be extension based exercise.
Distraction manipulation (done here at Boulder Sports Chiropractic) decreases intradiscal pressure and has been shown to effective for lumbar disc-related pain. We use a specific table here at BSC used to create more space around the nerve to reduce compression at that level. Using distraction will help to improve symptoms in order to prepare for a more active recovery in physical therapy. A study of 1271 low back pain patients determined that patients with related leg pain are considered to have a worse prognosis than patients with localized low back pain alone. Generally, the farther down the leg someone is having symptoms, the more severe the injury is and the harder it will be to treat successfully with conservative measures.
Judicious application of sciatic nerve flossing may help mobilize and desensitize irritated nerves, however caution should be used with acutely irritated nerve roots as nerve flossing may increase a chemical inflammatory response and therefore more pain. With that said, the technique is very effective for sub-acute and chronic nerve root irritation. Spinal mobilization with movement may help disc-related radiating pain. Myofascial release techniques would be performed on muscles of the lumbar spine and hip including the quadratus lumborum, lumbar erectors, psoas, piriformis, gluteus and tensor fascia latae (TFL) muscle. Therapeutic stretching should be performed to areas of tightness in the spine, hips, and thighs. Ice and laser modalities may alleviate some of the symptoms associated with lumbar disc bulge.
In addition to above treatments, physical therapy should be implemented to introduce a home rehabilitation program. It would include a combination of exercises to address spinal mobility, core stabilization (including abdominals, gluteal muscles and large muscles of the legs) as well as sciatic nerve flossing. Lumbar disc bulges have been shown to trigger fatty infiltration and weakness of the superficial and deep spinal stabilizers. Exercises should be prescribed for any identified functional weakness as strength around the disc will be the most effective long term treatment option. With that said, the most effective preventative measure for low back pain is strengthening. Being that recurrent low back has such a high incident rate after initial injury, it is worth it to proactively be strengthening related muscle groups including abdominals, gluteal muscles and leg muscles in order to reduce the risk for onset of low back pain.
Your Boulder Sport Doctors have treated many cases involving discogenic pain and disc bulge injuries with an extremely high success rate. Click here to make an appointment to get low back pain relief now.