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Severe back pain can result from a herniated lumbar intervertebral disc. Sometimes this is called a prolapsed disc, or bulging disc, or slipped disc (although the disc itself does not slip, only ruptures or herniates).
This happens when the soft viscous fluid nucleus bulges out beyond the damaged outer rings. Another type of injury is when only the outer ring of the disc (annulus) tears and this is termed an annular tear, as there may be little or no nuclear disc bulging through the tear.
The disc (or nucleus) can also chemically and/or mechanically (by pressure) irritate the surrounding tissue including the spinal nerves at or below the level of the spinal segment where the disc is injured. This can cause additional inflammation at the site of the disc injury and surrounding tissues. This can then result in neurological signs, e.g. parathesia, or sensory deficit, experienced as pain, tingling, numbness, pins and needles, or loss of sensation down the leg, often to the foot and toes.
Occasionally the motor nerves are affected as well, and this can result in loss of strength, muscle weakness and wasting, possibly foot drop, as the leg muscles become weak.
These symptoms of numbness or altered sensation down the leg may not necessarily be caused by a disc herniation. Please see the next page ‘Lumbar nerve irritation’.
The term sciatica is not accurate, and only suggests pain down the leg, without identifying its cause. Other causes for numbness and pain radiating down the leg can include a facet restriction with spinal nerve root irritation (which can respond very well to osteopathic spinal manipulation) piriformis syndrome where the sciatic nerve is irritated or compressed by a tight piriformis muscle. These are relatively mild causes of altered sensation in the leg, and a prolapsed disc can take longer to recover fully.
Osteopathic treatment for a disc prolapse can include manipulation above the level of injury take mechanical loading away from the injured area by ensuring that the entire spine works well as a unit, and the range of motion of any restricted spinal joints higher up the spine is improved. Any pelvic or spinal torsion can also be addressed to optimize symmetry and paraspinal muscle balance. In addition to better overall spinal biomechanics, the sympathetic chain and be down-regulated, and tends to modulate pain, and reduce pain perception.
Acupuncture can also be helpful, particularly as a local treatment near to the disc injury and the spinal level affected. Acupuncture here can promote soft-tissue repair, relieve pain, and reduce inflammation. Transcutaneous electrical nerve stimulation (TENS) can also be used in addition to acupuncture. Acupuncture also modules pain via endorphins and central inhibitory effects through the central nervous system.
After initial osteopathic treatment to lessen pain and mobilise or manipulate the spine above the level of injury (often L5/S1 or L4/L5) to help take undue mechanical load away from the injured area, as an osteopath, in later treatments, I can also guide you through effective rehabilitation. This includes Pilates type core-stability strengthening exercises. By increasing abdominal tone, one effectively strengthens the back. It is also very important to stretch and mobilise the thoracic spine, as facet restrictions here may also encourage the lumbar spine to become more unstable and relatively hypermobile. For more on this please see my page on Pilates and Core-stability.
For most disc injuries surgery has no significant advantage in the long term (see Waddell, The Back pain revolution, 2nd edition 2004). Even severe excruciating pain generally responds better to ‘conservative management’ i.e. physical therapy, osteopathy, acupuncture, TENS machines, and correct management (e.g. avoiding heavy lifting in the short-term).
An MRI scan can show the extent of any disc bulge and provide a definitive diagnosis. Many (most) disc injuries will completely resolve in under six to eight weeks. Even if one were to consider surgery, then the waiting list is often longer than this, and your injury will (hopefully) be much better in a few weeks. Osteopathy and acupuncture can reduce the pain, promote tissue healing and can shorten this recovery time.
Surgery is indicated (rarely) where there is loss of muscle strength and power. There may be muscle wasting, foot-drop, or loss of strength in the affected leg. Surgical decompression (or removal of a disc fragment) could be helpful in such cases. Cauda equina syndrome (retention, and bowels or bladder not opening) is a rare surgical emergency. Go to accident and emergency immediately, by ambulance (do not wait for a GP appointment).
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