“We tend to divide the examination of the spine into regions: cervical, thoracic, and lumbar spine clinical studies. 

This is a mistake. 

The three units are closely interrelated structurally and functionally – a whole person with a whole spine.  The cervical spine may be symptomatic because of a thoracic or lumbar spine abnormality, and vice versa! 

Sometimes treating a lumbar spine will relieve a cervical spine syndrome, or proper management of cervical spine will relieve low backache.” 

Disorders of the Cervical Spine 

John Bland, MD 

Professor of Medicine, University of Vermont College 

of Medicine 

WB Saunders Company 

1987 

Page 84

Treatment of Intervertebral Disc Herniation With 

Manipulation 

“Manipulation.  Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc.  This treatment is regarded as controversial and a form of quackery by many men.  However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery.  Occasionally, the results was dramatic. 

Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis.  The uppermost arm is placed backward behind the patient, pulling the shoulder back.  The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward.  The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back.  When this is felt, the relief of pain is usually 

immediate.  The maneuver is repeated with the patient on the opposite side.”

 “The patient should be cautioned beforehand that the 

manipulation may make his symptoms worse and that this is an 

attempt to avoid surgery.” 

Orthopaedics, Principles and Their Applications 

Samuel Turek, MD 

Clinical Professor, Department of Orthopedics and Rehabilitation 

University of Miami School of Medicine 

JB Lippincott Company 

1977 

Page 1335

A Patient’s Guide to Lumbar Disc Herniation

Introduction

Although people often refer to a disc herniation as a “slipped disc”, the disc doesn’t actually slip out of place. Rather, the term herniation means that the material at the center of the disc has squeezed out of its normal space. This condition mainly affects people between 30 and 40 years old.

Hopefully, this guide will help you understand

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is known as the lumbar spine.

The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people have an extra, or sixth, lumbar vertebra. This condition doesn’t usually cause any particular problems.

Intervertebral discs separate the vertebrae. The discs are made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. These fibers help the disc withstand tension and pressure.

A disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones. 

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity. They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

Causes

Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge outward. Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc.

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc.

Vigorous, repetitive bending, twisting, and lifting can place abnormal pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus, leading to herniation.

A lumbar disc can also become herniated during an acute (sudden) injury. Lifting with the trunk bent forward and twisted can cause a disc herniation. A disc can also herniate from a heavy impact on the spine, such as falling from a ladder and landing in a sitting position. 

Herniation causes pain from a variety of sources. It can cause mechanical pain. This is pain that comes from the parts of the spine that move during activity, such as the discs and ligaments. Pain from inflammation occurs when the nucleus squeezes through the annulus. The nucleus normally does not come in contact with the body’s blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. A disc herniation may also put pressure against a spinal nerve. Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve. This is called neurogenic pain.

Symptoms

What does the condition feel like?

Many cases of lumbar disc herniation result from degenerative changes in the spine. The changes that eventually lead to a disc herniation produce symptoms gradually. At first, complaints may only be dull pain centered in the low back, pain that comes and goes over a period of a few years. Doctors think this is mainly from small tears in the annulus. Larger cracks in the annulus may spread pain into the buttocks or lower limbs.

When the disc herniates completely through the annulus, it generally causes immediate symptoms, with sharp pain that starts in one hip and shoots down part or all of the leg. Commonly, patients no longer feel their usual back pain, only leg pain. This is likely because painful tension on the annulus releases when the nucleus pushes completely through.

Disc herniations produce inflammation when the nucleus comes in contact with the body’s blood supply (mentioned earlier). The inflammation can be a source of throbbing pain in the low back and may spread into one or both hips and buttocks.

A herniated disc can press against a spinal nerve, producing symptoms of nerve compression. Nerve pain follows known patterns in the lower limbs. It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes.

Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs. If this happens, a person’s reflexes slow. The muscles controlled by the nerve weaken, and sensation in the skin where the nerve goes is impaired. 

Rarely, symptoms involve changes in bowel and bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. These will include questions about where you feel pain and whether you have numbness or weakness in your legs. Your doctor will also want to know what positions or activities make your symptoms worse or better. Doctors rely on your report of pain to get an idea which disc is causing problems and if a nerve is being squeezed.

Then the doctor examines you to determine which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

X-rays are of minor help in diagnosing disc herniations. The discs don’t actually show up on X-rays. However, doctors can tell if the space between the vertebrae is smaller than normal. This can be an indication that wear and tear on one or more discs is causing problems. However, many peoples’ X-rays show degeneration of the discs. This is because degeneration in the discs is part of aging, like skin that wrinkles with time.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue. The image can show if a herniated disc is putting pressure on a spinal nerve.

Doctors may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal, called the the subarachnoid space. When the CT scan is performed, the dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated disc. 

When more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether a herniation is present. Like the CT scan, this machine creates pictures that look like slices of the area your doctor is interested in. The test does not require special dye or a needle.

Doctors sometimes order a specialized X-ray test called discography. In this test, dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of one or more discs. This test may be used when surgery is being considered to determine which disc is causing problems.

Doctors may also order electrical tests to locate more precisely which spinal nerve is being squeezed. Several tests are available to see how well the nerves are functioning, including the electromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if a herniated disc has put pressure on a spinal nerve. Another test is the somatosensory evoked potential (SSEP) test. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels. Doctors will often run these tests before performing surgery for a lumbar disc herniation. 

Treatment

What treatment options are available?

Nonsurgical Treatment

Unless your condition is causing significant problems or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may want your low back immobilized. Keeping the back still for a short time can calm inflammation and pain. This might include one or two days of bed rest. Lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. In rare cases in which bed rest is prescribed, it is usually used for a maximum of two days.

Chiropractic care is the “number one” treatment for disc herniations.

·      Moving the nucleus material back into the disc space is our (and your) number one priority.  

·      Often, there is a mantra we force our patients to memorize: traction and extension. 

·       Any motion that aids in the maintenance of these motions will be helpful to you.

 A back support belt is sometimes used for patients with lumbar disc herniation. The belt can help lower pressure inside the problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to atrophy (shrink). 

Doctors prescribe certain types of medication for patients with lumbar disc herniation. At first, you may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Severe symptoms that don’t go away may be treated with narcotic drugs, such as codeine or morphine. But narcotics should only be used for the first few days or weeks because they are addictive when used too much or improperly. Muscle relaxants may be prescribed if the low back muscles are in spasm. Pain that spreads down the leg is sometimes relieved with oral steroids taken in tapering dosages.

Surgery is, of course, a last resort.  There are numerous means of performing surgery on a disc, from “minimally invasive” to “nuts, bolts and screws” surgery.  Lumbar surgery has a poor success ratio, and even surgeons are hesitant to recommend cutting before all other options are tried.  ie treatment should begin with the least invasive methods first.

The Drs. at SLO Wellness Center are very familiar with these cases and have successfully treated disc patients with great results.  Your dedication to the recommended treatment plan consisting of  adjustments, therapies, and specific exercises will directly correlate to the rate at which you heal.

If you have any questions at any time, please do not hesitate to call to make an appointment at 805.543.8688.  

Manipulation 

[“Little known sequelae of sprains of the cervical spine”] 

Schweiz Rundsch Med Prax. 

[This is a German journal, and the article is in 

German.  The abstract is also in English] 

December 2, 1999 

88(49):2021-4. 

Kaeser HE, Ettlin T. 

“After cervical sprain not only pain and 

neuropsychological disturbances may occur, but 

also the following sequelae: cervical dystonia, and 

torticollis, dizziness, hearing loss for low 

frequencies, dysphonia and globus.” 

[Globus is a sensation of something stuck or of a 

lump or tightness in the throat.] 

“Except for dystonia the symptoms often 

respond to manipulation of a blocked articulation 

between occiput and atlas or axis and the third 

cervical vertebra.”