Disc Pain, Nerve Pain, Sciatica ...

Bulging discs can cause severe pain which can be both alarming and disabling. A disc herniation is a common cause of spinal surgery. I have developed a protocol for treating disc herniations without surgery or drugs which is safe and extremely effective. High tech mechanical treatments have been highly advertised and promoted in the news, but there is little evidence that these are any more effective and certainly are not more cost effective. And what they leave out is teaching you how to help yourself -- the critical component in effectively treating your pain and helping you prevent future pain.

Severe disc pain often causes pain that radiates along the course of the nerve. Severe nerve pain ranges from uncomfortable to truely intolerable. In the neck that means there is often pain radiating into the shoulder, arm or hand. In the low back the pain radiates into the buttock, hip, knee, or leg and foot. Disc compression in the midback can cause pain radiating into the sides, abdomen and groin.

Severe disc pain requires immediate and intense treatment. Drugs will only dull the pain. There is no drug treatment that will speed up healing.

Dr. Manlove's 3 Step Protocol for Disc Herniations

It is extremely important that you understand your condition so that you can help yourself. Passive treatment alone of any kind is not enough to get you the most rapid relief and to keep this from happening again.

1. POSTURE
Any forward bending will increase the pressure on the disc and prevent it from healing.

2. DECOMPRESSION
i have many specific treatments both in the office and home care that will take the pressure off the nerve and begin to allow it to heal.

3. CHIROPRACTIC ADJUSING
Chiropractic manipulation has a long history of safety and effectiveness for treating disc herniations.

A SYNERGISTIC EFFECT

In my 20 years of experience, I have found that combining ALL THREE of these approaches is many times more effective than applying only one or two of them.

Mild Disc Herniations frequently cause chronic symptoms because there are rarely correctly diagnosed or treated effectively.

Neck pain and headaches
Arm pain including carpal tunnel syndrome, elbow pain, "tennis elbow," etc.
Upper back pain.
Shoulder pain including rotator cuff syndrome.
Low back pan.
Hip pain and buttock pain.
Knee pain.
Foot pain.
Unexplained chest and abdominal pain.

A disc herniation can cause pain in at least several ways.

When the nerve is compressed the first sign is muscle weakness. Muscle imbalances frequently cause unusual stress on joints. This is a very common cause of conditions such as rotator cuff syndrome and tennis elbow, for example. Increasing pressure can cause muscle spasm. Much chronic upper back pain is caused by a disc herniation in the lower neck which is not severe enough to cause the classic radiating arm pain but can cause severe, persistent upper back pain. Finally, with even more pressure there is pain directly from the nerve which causes radiating pain.

In my experience many less severe disc herniations are missed, by both chiropractors and medical doctors, unless the pain is so severe that the diagnosis is obvious.
When properly diagnosed and treated many mysterious problems such as arm and hand pain, foot and knee pain, can be resolved.

I have developed a simple method of diagnosing disc protrusions based on simple neurology and mechanics that leads to much mor

e effective treatment and management of these common problems.

Disc herniations, disc protrusions and the "slipped disc"

The disc herniation is technically called a "focal herniated nucleus pulposis." It is sometimes called a herniation, a protrusion, a bulge or a slipped disc. Put simply, there is a tear in the tissue between the vertebrae. The pulp in the center of the disc is pushed through the tear and presses on the nerve, causing pain and/or weakness.

What is a Disc?

Intervertebral discs are the pads between each pair of vertebrae -- the bones that make up your spine. The outer part of the disc is called the annulus and is rubbery with fibers arranged in layers -- much like the composition of a car tire. Inside this is pulpy material called the nucleus.

If you look at the diagram to the right, the back of the body is to the left. The bumps you can feel along the spine on your back are to the left. So the discs are actually close to the middle of the body from front to back (this depends on how much front there is!).

Between the disc and the spinous process are the facet joints - one on each side. These are the joints that "click" in a chiropractic adjustment. When they are not moving normally (what chiropractors call a subluxation) they cause stresses on the disc that, over time, lead to separations between the layers of the annulus. Eventually, a weakened annulus can tear all the way through, allowing the pulpy annulus to bulge.

If you notice, the disc is somewhat kidney shaped. The weakest spot is at the two bulges (top of the picture, towards the back of the body). Unfortunately, this is where the spinal nerve comes out of the space between two vertebrae.

The spinal nerves connect the spinal cord and brain to the rest of the body. At the point where they are coming out of the spine, called the nerve root, they are quite vulnerable to being compressed. The bulging disc can compress the nerve causing either muscle weakness or pain or both. There may or may not be neck or back pain.

Symptoms depend on which disc and nerve root are involved. There are general maps of where the nerve from each spinal level goes, but there are also significant variations between individuals.

How is a disc herniation diagnosed?

The only definitive diagnosis is by MRI -- magnetic resonance imaging. That said, I find that using functional muscle testing and other tests, I have good success finding disc herniations. I usually do not order an MRI unless there are suspicious findings or a patient is not responding to treatment. When I do I my clinical findings usually agree with the MRI.

A regular x-ray sees only bone and the disc is soft tissue, so it is not visible on a simple x-ray. The MRI can see soft tissue. This is an expensive test. There are problems with people who are claustrophobic, are overweight or have certain metal implants or fragments since it involves putting the whole body in an extremely strong magnetic field -- enough to make a paper clip a dangerous missile. In addition, the MRI is done with the patient lying down. Some subtle disc herniations are only symptomatic in the seated or standing position and will not show up with the patient lying down.

Not too long ago many orthopedists would order myelograms. This involves introducing a special dye that shows up on x-ray into the cerebrospinal fluid that surrounds the spinal cord and then taking a series of pictures. The older dyes often produced inflammation of the tissues surrounding the spine and caused more problems. This inflammation could cause scarring of the tissues causing a chronic pain syndrome that is extremely difficult to treat.

According to standard medical texts 90% of disc herniations are found at L5/S1 -- the lowest segment at the base of the spine. Disc herniations at this level can be diagnosed by the straight leg raise -- the patient lies flat on the table. The doctor lifts a straight leg until there is pain -- usually radiating down the leg. Classically, there is leg pain, often severe.

In my experience disc herniations can occur at any level, but are often not diagnosed because there is often not a classical sign of leg pain and often not a positive straight leg raise -- remember these are only present if the disc herniation is in one of the lower two or possibly three segments of the spine.

I find that a careful clinical examination -- hands-on, in the office -- is both more sensitive and specific than any other test. In particular I have developed a sensitive testing protocol that works very well for cervical (neck) and lumbar (low back) discs. There have been many cases in which patients have had an MRI after seeing me, in which the imaging confirmed my specific diagnosis. The testing I use involves checking appropriate muscles for weakness in the seated position and then re testing them with the spine in extension (bending backward). In most cases extension will relieve the disc compression and return full muscle strength. This testing can detect a very mild disc herniation which may be causing problems such as hand pain or knee pain, but would otherwise be missed and also gives clues to what treatment is likely to be effective.

Treatment

In my experience, most disc herniations can be successfully treated in a fairly short time. The key is patient compliance. YOU must understand and apply simple principles that will allow the disc to heal.

The tear through the disc is like a cut. If you keep the edges together the cut will heal -- in most cases within a week or so. It may take somewhat longer for the scar tissue to become strong and stable and to treat the effects of muscle weakness and pain. And disc problems that have been present for a long time may take additional time to heal.

I can usually reduce the disc bulge in the office and show you how to keep it reduced. The problem is that it is very easy to reopen the tear.

Basically bending forward tends to cause the disc to bulge. It like a jelly doughnut -- if you bend forward you squeeze the disc and the jelly comes out the back, compressing the nerve. In a few patients, the bulge is large enough that bending backwards pinches the bulge and makes pain and weakness worse. We can determine this in the examination but it is relatively less common and usually improves to the point that backward bending reduces the bulge within a fairly short time.

Anything that puts pressure on the spine also squeezes the jelly out of the doughnut. So lifting, jumping, and things like jogging, trampolining, etc., can worsen the condition. Walking, on the other hand, is often helpful if there is not too much leg pain or weakness.

The ligaments that hold the bulge in tend to creep with time with just the force of gravity on the spine. Sitting tends to increase the bulge and especially sitting slumped -- which is a form of bending forward. But any sitting for long periods can be a problem. Running typically makes disc problems worse -- but remember that this is usually a temporary problem that can heal if properly treated.

Chiropractic Adjusting

In my experience, almost every disc herniation is associated with a joint problem at the same level (see subluxation ). In most cases the joint problem was there first and was the cause of the disc herniation. Restoring normal joint motion is an important part of rehabilitation. The disc does not have any blood supply. The is off white rafter than red or pink like the tissues with a rich blood supply. The vertebral body -- the bones on either side of the disc -- are marrow bones filled with blood. Even though the disc does not have a direct blood supply it is living tissue composed of cells. In order to stay healthy the disc depends on pumping of fluids from the vertebral bodies. This pumping action only happens if there is movement. A joint fixation means the joints are not moving. So one important part of healing the disc is restoring normal motion to the joints of the spine through chiropractic manipulation , and then maintaining that motion.

McKenzie Exercises

Robin McKenzie is a physical therapist form New Zealand who found that certain positions can dramatically relieve leg and/or arm pain in patients with disc problems. Generally, bending backward opens the disc space and reduces the bulge and therefore the pressure on the nerve. Occasionally some side bending is needed to find relief. In some cases there is pain into the arm or leg with bending backward especially with going too far back. This is probably a sign that the disc bulge is quite large and is being pinched and made to bulge more or it may due to joint pain. This is where a careful evaluation by someone with a real understanding of joint and disc mechanics is important. In most cases back bending exercises not only give immediate relief but are an important part of keeping the disc herniation reduced and giving it time to heal and in preventing future episodes.

Acupuncture

Acupuncture can be a valuable adjunct in treating disc problems. It is sometimes remarkably effective in relieving pain. I find it particularly effective in relieving the residual effects of nerve compression once the actual compression is relieved.

Posture

Avoiding all forward bending until the disc is healed and stable is absolutely vital to completely resolving the problem. As I am fond of telling patients, this is simple but not easy. I usually spend some time going through typical daily problems such as reading, working at a computer and brushing teeth. Often chronic areas of stiffness in the mid or low back make it difficult to maintain normal spinal curves and avoid stressing the area of disc herniation. Adjusting and stretching using the Percussor in the office and the back roller at home can be very helpful.

Traction

Traction means stretching the spine the long way usually using some kind of weight system. I have found that traction is usually very helpful in the neck, or cervical spine. I typically use supine (on the back) extension (bending backwards) traction. This involves lying on the back with the head hanging over the edge of a bed or bench and attaching a small weight to increase the stretch. I have found this has solved some very difficult neck and shoulder problems that would not go away any other way. Cervical traction is done at home and usually provides quite immediate and noticeable relief. It has the added benefit of restoring the cervical curve and improving posture.

For the low back I have found that home traction can be useful. There are a number of different units available, both locally and on the web. The equipment is somewhat expensive and cumbersome, but can solve some difficult chronic problems, in which case it is often well worth it.

Nutrition

Nutritional support for disc problems includes products that help with symptoms and those that support the healing process. I have found that proteolytic enzymes in quite high doses, for short periods, often provide dramatic relief. Glucosamine, chondroitin, MSM, other sulfur amino acids, manganese, vitamin A and C may all be key ingredients needed in extra amounts to support healing. Each individual is different.

Relation to Metabolic Sndrome

Metabolic syndrome includes the spectrum of blood sugar handling problems ranging from high insulin to diabetes. This condition is becoming epidemic. It is likely that the majority of even quite young Americans have some degree of increased insulin and insulin resistance even thought it is usually only diagnosed in its later stages. In this syndrome blood sugars attach to all protein structures including ligaments and the lining of the arteries, causing atherosclerosis. In the extreme case chronic sugar handling problems produce a condition of thickening and calcification of the ligaments of the spine called DISH. While this is speculation, it is likely that such stiffening and degeneration of connective tissue plays a part in the process of disc degeneration and herniation.

Emotions

Stress -- that is any challenge to the system which produces a prolonged adrenal response -- is a frequent component of back pain. Stress is associated with increased muscle tension especially in the back muscles. In Chinese medicine this is thought of as deficiency in the kidney meridian (over worked adrenal glands) and compensatory over energy in the bladder meridian which runs through the back muscles. There are a number of energy techniques which are very effective for relieving emotional distress .

Rehabilitation- preventing the next episode

Working with "abdominal hollowing," which involves learning to isolate and hold the lower abdominal muscle, is usually safe even early in treatment.

Once the disc is stable strengthening exercises can be added. Long term management includes:

Posture and ergonomics - your mother told you to sit up straight! Rethinking how you use your body at work and at home is the key to prevention.
Flexibility including stretching and periodic adjusting to keep the small joints of the spine mobile.
Strengthening primarily of back and abdominal muscles.

Lumbar Stabilization

Research mainly coming from physical therapists in New Zealand, shows that people who have low back pain lose strength and coordination of the deepest layers of the core muscles. Most rehabilitation has focused on strengthening the big, outer layers and this approach has not been particularly effetive. Lumbar stabilization involves working with you so that you learn to feel these deep core muscles and then practice using them as a first stage of rehabilitation BEFORE you begin a program of strengthening the bigger muscles of the abdomen, back, hips and legs. This approach has been shown to be extremely effective in preventing future episodes of back and neck pain.

Are X-rays or MRI's necessary?

The disc is soft tissue and does not show up on regular x-rays. Disc herniations can be seen with an MRI scan. If I find something unusual in the history or examination I will order x-rays, but I do not order them routinely. A single low back x-ray examination gives enough x-ray exposure to equal the risk of smoking a pack of cigarettes a day for a year. I only order an MRI if there are particularly puzzling findings, if the symptoms are especially severe and there is some likelihood of surgical referral, or if there is no progress after a reasonable amount of treatment. The MRI is quite expensive. In most cases I can pinpoint the problem adequately with a good physical examination. Finally, the MRI is performed with the patient lying down. Frequently this position relieves the disc bulge, which then does not show up on the MRI.

Medical referral

Occasionally patients are in significant pain that cannot be adequately relieved by conservative treatment and in that case I believe they deserve good pain management. The pain of true nerve compression is only relieved by narcotics which requires a medical prescription. In some cases the symptoms warrant either further diagnosis or surgery. I do not hesitate to refer when appropriate. In many cases the patient seeing me and a primary care provider and I am glad to share notes and coordinate care.

Surgery or other invasive procedures are a last resort and studies show that patients who do not have surgery usually do better in the long run. It is important to understand that surgery is usually no more than symptomatic treatment, that is it does not address underlying problems of back function, and it has other risks. I am always available to discuss the risks and benefits from my point of view, which, I admit is not unbiased, but is based on experience.

Prognosis: what you can expect

Simple disc herniations usually respond within a short number of visits. Most patients recover. I will tell you on the first visit whether I think I can help you and give you my best estimate of how long it will take for you to get over the nerve compression. Both of us should know whether this is working or no within one to three visits. Most problems are resolved within 4 - 6 week at the outside. Complete rehabilitation can take longer but usually involves fewer and less frequent office visits. The length of time depends on age, history of injury and back or neck pain and overall health and physical condition. I believe in giving you choices and letting you make the decision.

Disc herniation, recurring back pain and spinal degeneration

If the disc herniation is not properly treated, in many cases the pain will resolve but there is a very high incidence of return of pain months, or sometimes years, later. The natural course of chronic back pain is for episodes of increasing frequency and severity -- it happens more often and is worse and worse. Meanwhile, even while there is no pain, the process of spinal degeneration is going on. In addition to pain, lost time from work, limitations on activity, and expense, recurring back pain sets the stage for spinal stenosis in which there is actual bony pressure on the nerves.

The good news is that this condition is treatable and there is a clear path to prevent recurring symptoms & degeneration.

If you have further questions or comments, please feel free to contact me: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. . '; document.write(''); document.write(addy_text57613); document.write('<\/a>'); //-->\n This e-mail address is being protected from spambots. You need JavaScript enabled to view it. I offer a free, brief consultation to discuss how I can help you or someone you care for.

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Disclaimer: The entire contents of this website are based upon the opinions of Dr. Manlove, unless otherwise noted. The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Dr. Manlove. Dr. Manlove encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional.

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