If the disc is herniated it can be protruded/extended or sequestered.
This is basically when the tough annulus part of the disc has gotten
a tear or blowout in it, and some of the inside of the nucleus has
come out. This is Herniated Nucleus Pulposus (HNP). Even still,
when the nucleus material (which is kind of like toothpaste) comes
out, it too tends to shrink down with time. (Have you ever squeezed
out toothpaste and left it on the sink overnight? The next morning
it has shrunk as the water dried out of it.) If the herniated disc
material shrinks enough, the squeezing and irritation to the nerve
root gets less and the nutrition and blood supply return to the
nerve root, and it stops complaining. The pain, numbness, and weakness
goes away. How do you get this to happen?
1) Stay active
Think of it this way. Your heart is a pump. It pumps the blood
through the arteries to the nerves. But, as the blood passes through,
it needs to enter the veins. The veins have very little pressure,
about 5cm of water. What pumps the veins are the muscles. When
the muscles contract they pump the blood through the nerve and
back to the heart. If you stay inactive, sit still, stand still,
or lay in bed, you are stopping the muscle pump, and just when
you need it most. By doing Aerobic exercises and getting the pump
going, you get that blood to the pinched nerve and the nutrition
to the discs so they can heal. If you are inactive, not only do
you stop the muscle pump, but also you begin to get weak. Estimates
are that you lose 1% of your muscle strength for each day of inactivity.
How many of us can afford to lose 5-20% of our strength? But this
is the effect of 5-20 days of bed rest. Bed rest also effects
other body functions, such as the ability to think, see, and hear
clearly. Inactivity leads to all these bad side effects, and begins
to perpetuate the problem. Estimates are that when we are forty-five
years old we need 45% of our normal strength/power to get through
a normal day, but by age seventy-five, we need 90%. So the effects
of inactivity/bed rest are worsened with age. One day of bed rest
is okay while you begin other parts of the program (i.e. ice,
anti-inflammatories), but any more leads to problems.
2) Use Ice
If we had a medicine that would make blood supply/nutrition go
to a specific place in the body, we would give it to you. We don't.
Most anti-inflammatories work systematically, and all have side
effects. Ice will increase the blood flow to the deep structures
(nerves, muscles, and ligaments), and help get the swelling down.
Both ways help to relieve pain and improve the healing. The optimum
is to use and ice pack twenty to twenty-five minutes and no more.
This can be repeated every two hours. Watch your skin so that
you don't get frostbite, but with the new form of packaged reusable
soft ice this rarely occurs. Heat does not work. While it makes
it feel better for a while by relaxing the muscles, it also makes
the blood supply come to the skin and takes it away from the deep
structures. This perpetuates the problem.
3) Medications
Anti-inflammatories: Aspirin, Ibuprofen, Aleve (not Tylenol)
These medicines help to decrease the inflammation if you can
get blood flow to the effected area. These need to be taken regularly
and at advised dosages. Some people respond like a miracle to
some medication, others do not. So, if an anti-inflammatory isn't
working, it is often useful to try another. Contact your physician.
Many people get side effects form antiinflamitories: Upset stomach,
bleeding, eye, kidney, and other effects, so you certainly should
use them under the care of a physician. Antiinflamitories are
better at keeping the swelling down than at getting the swelling
down. So, start its use early, and it is more effective. Once
the pain is gone, it is rarely necessary or prudent to continue
use of the medication.
Muscle Relaxants: Often useful for a brief time, but usually
cause sleepiness and depression. You should not operate a car
while using them. They do not relax the muscles in a direct way,
but have a more central effect. They are especially useful to
get some relief for sleeping at night. Muscle relaxants can be
habit forming.
Narcotics: Usually are not very useful. When you take a narcotic,
you basically block the pain messages, but you are not improving
the blood flow or strengthening the muscle. It can be moderately
useful if it allows you to undertake an exercise program to improve
blood flow/nutrition and muscle strength. Remember, they are allowing
you to ignore the pain signal/warning, so they allow you to do
things that are potentially damaging, such as sitting or lying
too long in one position. They also cause sleepiness, depression,
constipation, upset stomach, and are habit forming. They are not
useful for chronic pain because of the above cautions, and because
even the good effects diminish as the bad ones increase.
Chiropractic: Can be useful if it decreases the muscle spasm
or tightness of the muscle. If you are then able to undertake
an active exercise program and function improving the blood flow,this
is very useful. Basically, try it. If you feel improvement, it
is useful to have repeated manipulations. However, it does not
make the disc slip back in. In the long run it only works by improving
blood flow. If a manipulation increases the pain it may be actually
pinching the nerve more. If numbness or weakness worsens, you
need to try something else.
Massage: As with Chiropractic, can temporarily decrease muscle
spasm and increase blood flow, but will only be effective if you
start the exercise program and continue the blood flow.
PT/Exam: Aerobic Lumbar Stability. The idea is to improve the
muscle pump without pinching the nerve by bending or twisting
the spine.
Spinal Stenosi s/Pseudo-Cl audi cation Muscle Cramps in the Legs
with Activity, Relieved by Squatting or Leaning on a Shopping Cart
As you try to walk you get a pain or cramping in your buttock or
posterior thigh or calf that gets better if you stop, squat, or
lean on a cart. This arises because the cross section area inside
the spinal canal has gotten smaller. This can come about because
of a herniated disc, but frequently arises because the joints of
the spine have enlarged and grown inwards, taking away the space,
squeezing the nerves, and therefore slowing the nutrients or blood
flow to the nerve. Frequently, there is no back pain simply because
as the joints enlarge, they sort of naturally stabilize the spine
and fuse it. The pain arises because the joints did this slowly,
often over the course of years, enlarging the joint and growing
into the spinal canal, taking away space for the nerve and causing
resistance to blood flow. This can effect you suddenly just like
the straw that broke the camel's back, the squeezing is too much
to get the blood flow/nutrients to the nerve and they begin to complain
and not work. When you rest enough blood flow gets to the nerves
so you can walk a little farther. But when you try to walk they
just can't got enough blood flow so they begin to hurt at about
the same distance. This becomes a worsening problem because if you
can't walk you begin to lose strength in the back muscles, which
stresses the joints more and makes them enlarge further, causing
more compression on the nerves and less blood flow. You can't stay
healthy if you can't stay healthy. Therefore, early treatment with
ice, anti-inflammatories, physical therapy, chiropractic, and massage
can help for a while, but if the joint is squeezing the nerve and
limiting the blood flow, the symptoms will become more frequent
and more serious. Once the joints have enlarged, they can either
stay that large or get bigger, but they do not tend to get smaller
without surgical intervention.
The enlargement of the joints is caused by Osteoarthritis. This
is the same type of arthritis that causes the joints of people's
hands to enlarge. Many people have very enlarged finger joints without
much pain, only symptoms of stiffness. The same process of stiffening
up your back does not lead to pain unless you continue to try to
bend through. If the joints grow outwards, you are okay. If the
joints grow inwards, you only get into trouble when they begin to
limit blood flow and squeeze the nerves. This can be made much worse
if you continue to bend, inflame and stress the joints, causing
them to enlarge further. Fighting the natural tendency of your back
to stabilize itself can only lead to further problems.
When is Surgery Necessary?
Sometimes surgery is necessary to enlarge the spinal canal and
remove the part of the joint that has grown inwards. The surgery
is particularly successful if the spine has basically stabilized
itself by shrinking the disc to 60% water, and enlarging the joints
outward. But, how do you know when it is appropriate to go to the
Surgical Option?
As we said earlier there are many menu options. At least some of
these should be tried before surgical intervention. Most people
do respond to one or more of these options. I basically ask patients
on return appointments if they are getting better, staying the same
or getting worse. If they are getting better we are obviously going
the right direction. If they are getting worse or staying the same
we need to try something else. If none of the easy things are working
and the person is still experiencing significant limitations then
we may consider surgery. Remember, you cannot stay health if you
cannot stay active. For every day you are not walking at least 10
minutes 3 times a day you are losing strength. Estimates are that
while you lose strength at the rate of 1% per day, you can only
gain it back at the rate of 1 % per week. This means that somewhere
relatively early on it is important to get to the point where you
have resumed at least some level of exercise. If you are unable
to get active Surgery should be considered.
It is important to understand that surgery does not remove your
spine and replace it with a new one. Surgery is always a patching
up type of intervention. It often improves the anatomic problem
by removing what is pinching the nerve or limiting the bloodflow,but
it does not make you normal. It allows you to resume activity and
improve the blood supply so your body can heal and get back towards
normal. Surgery is a 90:10 deal. It can do about 10% but you still
need to do your 90%. It is not like carpentry where you can go in
and connect two things and you are done. It's more like gardening.
Surgery can prepare the area but it is the daily activity that restores
the blood flow and restrengthens the muscles. Just like gardening
it takes a season to get the results you want. If you plant your
garden, but never water it or care for it or worse yet poison it
(by smoking) you wouldn't expect much of a crop. However, if you
take care of it everyday at the end of a season you could expect
a prize-winning result. As I said earlier, you can only regain strength
at the rate of 1 % per week and that is if you exercise at least
5 days per week. I believe that while you may feel pretty good after
6-8 weeks it will really be 100 weeks until you are back to 100%
of what you should be for your age. The real problem is that at
age 45 it only takes 45% of your strength to get through a normal
day. Therefore, you may feel O.K. as you get to that level but given
that you now have a patched-up back you need to aim for that 100%
level to keep your back well protected to avoid problems as your
increasing age makes increasing demands of the percentage of your
strength it takes to function normally.
Other information can be found at:
Bulging Disc
Intervertabral Discs
Prolapsed Disc
Protruded Disc Disease Has Higher Recurrence of Disc Herniation
Herniated Disc Treatment - Treatment Options for a Herniated Disc
Symptoms of a Herniated Disc
Herniated and Bulging Discs
