Your Guide To Slipped Discs, Disc Herniations, Disc Bulges, Disc Protrusions and Disc Extrusions

By Dr Ken Nakamura+

 Disc Bulge: Why Is Your Disc Bulging & Best Treatments For Disc Bulges

Do you have a disc bulge that is causing you incredible pain in your lower back?

 

Does your disc bulge give you sciatica or pain down your leg?

 

Have you wondered what’s going on in your lower back to cause all this pain?

 

In this issue of  Bodi Empowerment I go over what’s going on with your disc bulge, the cause of your pain and what kind of  treatments are best for you. In other words I act as guide to help you decide what to do.

 

Disc herniations, or disc bulge occur when the disc that is found between vertebrae in the spine is damaged. Most of the time the damage occurs in stages.

Disc Herniation Stages

Here are the four stages of a disc herniation or disc bulge:

  • Disc Bulge
  • Disc Prolapse
  • Disc Extrusion
  • Disc Sequestration

Think of the disc like a flat hard onion with strawberry jelly inside. The jelly is the nucleus while the onion layers form circular layers of hard cartilage called the annulus.

 

Lumbar Disc Herniation-Downtown Toronto Chiropractor

Disc Bulge

If you were to damage the annulus (onion) enough the disc gets to a point that when you bend forward, you pinch the front of the onion so it starts to bulge the onion at the back by pushing the nucleus (jelly) backwards.

 

This is called a disc bulge. For most of you there is no pain but for some of you there can be considerable lower back pain and even sciatica from this small disc bulge.

 

Disc Protrusion

A disc protrusion is like a disc bulge that comes out even more in one focused spot. The disc pushes out as if you had your finger inside a balloon and pushed out.

 

Most of the layers of the onion (annulus)  have been damaged but the jelly (nucleus) is under considerable pressure. The jelly (nucleus) squeezes through the layers of the annulus (onion) with the few intact layers of the onion (annulus) and a the PLL (posterior longitudinal ligament) holding the jelly from spilling out. The disc is still contained by the  annulus and PLL ligament. ie the balloon hasn’t popped.

 

Disc Protrusions usually cause quite a bit of lower back pain and often times sciatica. Many of you, with disc protrusions, on the other hand, have absolutely no pain. There is no clear reason. A study found that 40% people with no pain what so ever had disc protrusion confirmed by MRI (Magnetic Resonance Imaging Machine) [1]

 

The trick is not to let your doctor diagnose you based on just a MRI. An MRI that shows a disc protrusion by itself is not a diagnosis. It’s what a normal person with no pain can have. Make sure there is other evidence!

 

Disc Extrusion

 

Disc Extrusion is a disc bulge so large that it breaks through the last layers of the onion (annulus) and the PLL ligament pushing into the area of the spinal cord. ie. The balloon has popped. If you have an extrusion you likely have a tremendous amount of pain leg pain and usually some lower back pain.

 

Surprisingly when a group of normal people with no pain  were scanned  with an MRI 18% were found to have disc extrusions (severe disc herniations). [1]

 

When you have a disc extrusion chances are the extrusion is likely causing your pain as it’s so large.

 

Disc Sequestration

 

A disc sequestration occurs when a piece of your jelly (nucleus) that breaks through the onion (annulus) and the PLL ligament has now broken off and moved away further into the spinal cord area. When you have a disc sequestration you have a tremendous amount of leg pain and with some lower back pain.

 

Smaller Is Better

 

Disc Herniations or slipped discs are better if they are smaller, right? You will have less pain right? Yes except when they give you pain. Remember all those normal people with no pain with all kinds of slipped discs. They had disc bulges, disc protrusions, and disc extrusions and even disc sequestrations with no pain.

 

On the other hand, even with a small disc bulge you can get a lot pain and even sciatica with no pressure on the nerve. So smaller isn’t always better.

 

Bigger Is Better

 

Sometimes bigger is better. Most people like you with a disc extrusion and sequestration have lots of pain. The fact is these painful extrusions while more painful usually shrink with time. It takes about a year but with the shrinking of the herniations the pain does decrease.[2-5]

 

 

Disc Herniation (Slipped Disc) Treatments

#1 Stop Aggravating Yourself

 

 

Half the problem why people don’t get better is that they continually aggravate their lower back and their slipped disc. By learning to lift properly, sit properly and even standing over the sink while brushing your teeth properly can help you avoid the pain.

 

Even Yoga exercises such as the downward dog can aggravate the lower back, Pilates and even your basic abdominal crunch has been shown by Dr. Stuart McGill to increase the pressure in the disc beyond it’s safe limit.

 

If you want to find out how to stop aggravating your lower back, click the link below.

 

See Also: Slipped Discs: Best Self-Treatments To Help Your Lumbar Disc Herniation

 

#2 Exercise For Disc Herniations / Slipped Discs

For a complete instructions on exercises for slipped disc click the link. Best Exercises For Your Slipped Disc

 

#3 Chiropractic Adjustments

 

A major research paper showed that people that have had lumbar disc herniations who have failed at least 3 months of medical management, including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture, should consider chiropractic spinal manipulative treatment, followed by surgery if unsuccessful. [6]

 

I would also add that I would try 3 different chiropractors as the competency level varies from person to person. Like any profession including medical doctors and physiotherapists there are the good ones and bad ones.

 

See also: 6 Things You Should Look For In A Chiropractic Clinic

#4 Acupuncture

 

Acupuncture has been found to be helpful for Slipped Discs in the neck and the lower back.[7-8]

 

#5 Injections

 

In a study of two different groups getting treatment for lumbar disc herniations, the group getting chiropractic manipulation had 76.5% of the people improve while the group getting the nerve root injections improved by 62.7%.

 

After a period of a month the chiropractic spinal manipulation group had a 60% reduction in pain compared to the nerve root injection group, which had a 53% decrease in pain. Keep in mind the nerve root injection group seemed to be worse to start with compared to the spinal manipulation group.

 

See Also: Chiropractic Spinal Manipulation Vs. Nerve Root Injections for Lumbar Disc Herniations

 

Epidural injections are also helpful for lower back pain and the radiating pain down your leg.[8]

 

 

#6 Surgery

#1 Disectomy

 

There are two types of surgery available for slipped discs. Discectomy and spinal fusion. Discectomy involves cutting out the piece of the disc that is protruding out and pushing on the spinal cord or nerve.

 

Disectomy is relatively simple compared to spinal fusion. You have a much better chance of success with discectomy if your MRI shows that your disc herniation is greater than 7 mm thick and correlates well with your neurological exam, and nerve conduction studies.[9] If your lower back pain is greater than your leg pain discectomy will not likely work very well for you.[10]

 

#2 Spinal Fusion

 

Spinal Fusion removes the disc herniation, jelly (nucleus), and most of the annulus (onion). Bone from pelvis is than transplanted where your disc was so that the two vertebrae become one.

 

What Treatment Should You Do?

 

You should do at least 3 months of therapy when you have a slipped disc before even considering surgery or injections. Start by not aggravating your lumbar disc. You need to modify how you bend forward, lift and even how to pick-up your socks.

 

See AlsoDisc Herniation: Best Self-Treatments To Help Your Lumbar Disc Herniation

 

If you have trouble sleeping at night you can take pain killers to help you get a better sleep. Don’t stay in bed though. When you have excruciating pain you should only have bed rest for a maximum of two days total.

 

Next try chiropractic or physiotherapy with someone that also does acupuncture. Make sure it’s not with somebody that knows how to do 20 acupuncture points. Be patient with them as disc herniations can be difficult to deal with.

 

Attend regularly 3 times a week for at least a month . Make sure they change the treatments to find what works best for you. If they keep doing the same thing each visit but you are improving that is fine, but if you aren’t improving than it’s time to find a new chiropractor.

 

If you don’t get any better after a month change to a different chiropractor.  I recommend trying 3 different chiropractors as different chiropractors have different training.

 

If you plateued or haven’t improved at all than it’s time to get a nerve root injection or a epidural injection. Make sure it’s with a person that does this every day. An emergency room doctor or family physician only does this procedure once in while. It’s better to get someone more experienced.

 

When conservative care has been completely exahausted than it’s time to consider surgery. Discectomy is more conservative than spinal fusion and recovery is much quicker. You should consider disectomy surgery if you have :

 

  • Foot drop that is getting worse.
  • Any other neurological symptoms that is getting worse like your reflexes, sensitivity
  • Bowel or Bladder Symptoms (loss of your poo and pee function). : This is an emergency you should go to the hospital right away.
  • If you have a disc protrusion or  that is 8 mm or larger that correlates well with a neurological exam, and  Nerve conduction tests.
  • Leg pain is worse than your lower back pain.

 

Beware of the surgeon that wants to operate on a small disc bulge. There are too many unnecessary surgeries in the USA especially spinal fusion.

 

Spinal fusion is considered when your lower back pain is worse than your leg pain

 

Tell us what you think in the comments below and like us on Facebook. This Toronto Downtown Chiropractor will answer all questions in the comments section.

 

Research

1. Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities, and osteoarthritis of the fact joints in Asymptomatic Volunteers.” Radiology – 1998; 209:661-666

2.  Maigne JY, Rime B, Delignet B. Computed tomographic follow-up of 48 cases of nonoperatively treated lumbar intervertebral disc herniation. Spine 1992; 17:1071-1074.

3. Ikeda T, et al. Pathomechanism of spontaneous regression of the herniated lumbar disc: histologic and immunohistochemical study. J Spinal Disord 1996;9:136-140.

4. Ahn SH, Ahn MW, Byun WM. Effect of transligamentous extension of lumbar disc herniations and their regression in the clinical outcome of sciatica. Spine 2000; 25:475-480.

5. Komori H, Shinomiya K, Nakai O, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine 1996; 21:225-229.

6. McMorland G et al.Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative & Physiological Therapeutics 2010; 33: 576-584.

7. Wu, Yao-chi, Jun-feng Zhang, Yi-jun Sun, Cheng-fei Huang, Ping Shao, and Gui-zhen Liu. “Clinical study on electroacupuncture for cervical intervertebral disc herniation.” Journal of Acupuncture and Tuina Science 11, no. 6 (2013): 371-374. – See more at: http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1249-acupuncture-found-superior-to-drug-for-neck-disc-pain#sthash.vD0pNepM.dpuf

8. Wang HeshanNon-Surgical Therapy For Prolapse of Lumbar Intervertebral Disc. The Journal of Traditional Chinese Medicine

9. Parr AT, Diwan S, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back pain and lower extremity pain: a systematic review. Pain Physician 2009;12:163-188.

10. Carragee EJ, et al “Clinical outcomes after lumbar discectomy for sciatica:   The effects of fragment types and annular competence” J Bone Joint Surg Am – 2003; 85(1):102-108

11. McMorland G et al.Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative & Physiological Therapeutics 2010; 33: 576-584.


Author

Dr Ken Nakamura


525 Responses to Your Guide To Slipped Discs, Disc Herniations, Disc Bulges, Disc Protrusions and Disc Extrusions
  • Amanda D. says:
    September 13, 2018 at 5:24 am

    Hi Dr. Nakamura. First off, I want to thank you for writing an article that the general public can understand. I had received the results of my cervical MRI and was at a complete loss of understanding until I found this article. I was diagnosed with JRA (Juvenile Rheumatoid Arthritis) at the age of 9 and was told by several rheumatologists throughout my life to avoid surgery at any cost due to the rheumatism. Anyway, my current rheumatologist just told me that my current MRI said I have 2 herniated discs & is referring me to a pain management specialist/anesthesiologist, in order to get a shot in my neck. I get the cortisone injections in my knees, so, I’m quite used to them. I once went to a chiropractor and had a bad experience, when I was in my early 20s) and I am very hesitant to go back to a new one. I understand that there are good and bad chiropractors, but my rheumatologist feels that with my condition, manipulation of the joints would not be a good idea. Sorry this is so long. I have 2 questions, if I may. After reading your article, I now understand that one of my disc herniations is at the extrusion level, as my diagnosis says, “broad based 0.26 cm central herniation of the disc indenting the anterior thecal sac and contacting the cord at c2-c3.” C3-c4, c4-c5 & c5-c6 do not say anything like that. Question #1: is .26 cm a small, medium or large herniation? Question #2: which of the following is the second herniation? -“posterior spur and disc complex effacing the anterior thecal sac and right uncinate spurring producing moderate right foraminal narrowing at c3-c4”, “posterior spur snd disc complex effacing the anterior thecal sac and bilateral uncinate spurring producing mild bilateral foraminal at c4-c5”, or, “posterior spur and disc complex wffacing the anterior thecal sac and producing mild cord flattening and right uncinate spurring producing moderate left foraminal narrowing at c5-c6?” The only differences I can see are in the uncinate, whether it be right or bilateral, the forminal, whether it be moderate right narrowing, mild bilateral, or or moderate left narrowing. (I have actually no idea what any of this means) Also the last one says mild cord flattening, this does not seem to fit in with your explanation of a herniated disc. Would you please, as you so eloquently did before, use layman’s terms and explain. Thank you so much in advance. Amanda

    • Dr Ken Nakamura says:
      January 13, 2019 at 8:36 pm

      Thanks for your question Amanda.
      Answers to your question.
      1. 0.26cm or 26 mm is no considered a large disc herniation. It would be considered small to medium.
      2. Keep in mind your symptoms are more important than what the MRI says. While you may have “moderate right foraminal narrowing” you don’t actually say what your symptoms are except to say that you got an injection in your neck. Often times MRI finding and symptoms don’t correlate that’s why your symptoms are so important.

      So, without the proper information, I can’t give you an informed opinion. To answer your question the area of most interest is at C34 where there is a moderate narrowing of the foramina which means that the nerve that comes out of between two vertebrae is narrowed so there can be pinching of the nerve. Just because there is a narrowing of the hole for the nerve doesn’t mean there is pinching of the nerve. That’s why there is no correlation between symptoms and MRI according to many research studies.

      “posterior spur and disc complex effacing the anterior thecal sac and bilateral uncinate spurring producing mild bilateral foraminal at c4-c5”
      This means that bones have started to change shape so that it is sticking out. Combined with the disc that is sticking out these together are which is pushing on spinal cord mildly.

      “right uncinate spurring producing moderate left foraminal narrowing at c5-c6?” This doesn’t make sense unless the spur is gigantic going across from right to left. The MRI would indicate that the spur is gigantic if this was true. More likely this is not true. Likely it was the “left uncinate”. However, you only gave me bits and pieces of the MRI and not the whole MRI so I don’t have the whole context of what was written.

      Hope that helps. The above is an opinion and not a recommendation.

      If you have any more questions regarding your neck, this Toronto Chiropractor will do his best to give you a good answer to your question.

  • Noman shaukat says:
    February 23, 2018 at 6:07 pm

    Hello dr.ken nakamura
    Im Noman from pakistan i haveing a lower back pain and in leg specialy when standind or walking i do MRI
    MRI report .straightening of lumbar curve.
    Diffuse disc bulge more towrds in right side is seen at L5 – S1 level causing effacement of anterior thecal and lateral recesses.
    Facet joints and ligamentum flavum hypertrophy and desiccatory changes are seen at the same levels.
    Vertebare: ( Normal)
    Vertebral marrow: (Normal)
    Posterior neural arches:(Normal)
    CONCLUSION: diffuse disc bulge more towards right side at L5 S1level causing effacement on anterior thecal and lateral recesses.
    Dear doc. first i consult with Neuro doc he suggest me to opprate thn i consult with Orthpadic doc he say aviod opprate start meddicine he gave me pain killers 3 types and 2 types calcium medi. I use 1 month but no improvement i consult with therapist for 1 week but failed. Know dear Doc told me what should to doo how to get rid with that.
    Thanks n regard Noman shauakat

    • Dr Ken Nakamura says:
      March 1, 2018 at 10:57 pm

      Thanks for your question Norman. As for surgery, the rule is that you always do conservative therapy first. However, keep in mind I have not examined you. At the same time, you are getting two different opinions on the same condition. These exercises in this article will likely help you. Here it is: https://www.bodiempowerment.com/herniated-disc-part-2-the-best-exercises-for-your-herniated-disc/

      The above is an opinion and not a recommendation.

      Hope that helps your slipped disc. If you have any more questions for this downtown Toronto chiropractor just let me know and I will do my best.

  • Ramesh Lokhande says:
    February 10, 2018 at 7:54 pm

    Dear Sir,

    My Name is Ramesh. I am 36 old and working in private sector as desktop engg i.e My daily sitting on chair almost 8 to 10 hrs.

    i have lower back pain and neck pain since last 4 to 5 months.

    In neck pain sometimes it will pain my head as well.

    Back pain is very critical it will start when i sit more than 15 to 30 minutes and then pain continues.

    When i sleep there will no pain in back.

    i did physiotherpy for one month but still no improvmnet.

    please suggest how i can treat further to solve my back and neck pain problem .

    Which Dr will help me in this problem (orthopedic/neurologist/rheumatologist…etc)

    Will Acupuncture help to reduce back pain ?

    shall i use back belt ?

    MRI REPORT:

    Imaging sequences:
    ===================

    SE T1W Sagittal and axials FSE T2W sagittal & axias

    Findings:
    ==========

    1. There is loss of normal T2W bright signal in L2-L3 intervertebral disc suggestive of partail disc dessication.
    2. Rest of the vertebral bodies are normal in height morphology and signal charactristics
    3. Spinal cord and cauda equina are normal in signal intensity
    4. spinal cord ends at L1-L2 level

    Degenerative disc disease of the lumbar spine with changes at varous lavel as described below in decreasing order of severity.

    At L2-L3 Level :Diffuse disk bulge is noted identing the thecal sac ,narrowing bilateral neural foramina and abuting left exiting nerve root.

    Left extra-foraminal annular tear and mild ligamentum flavum thickening is noted at this level.

    At L3-L4 Level :Central and bilateral paracentral disc buldge is noted identing the thecal sac, narrowing bilateral neutral foramina without any nerve root compression.

    AT L4-L5 Level :Central and bilateral paracentral disc buldge is noted identing the thecal sac, encroaching bilateral neutral foramina just abuting bilateral existing nerve root.

    At L5-S1 Level :Central and bilateral paracentral disc buldge is noted identing the thecal sac, encroaching bilateral neutral foramina just abuting bilateral existing nerve root.

    Right annular tear is noted ar this level.

    Lumar canal diameter at disc level are as follows.

    L1-L2=15 mm
    L2-L3=12 mm
    L3-L4=11.6 mm
    L4-L5=11.5 mm
    L5-S1=11.7 mm

    • Dr Ken Nakamura says:
      March 1, 2018 at 11:06 pm

      I did physiotherapy for one month but still no improvement.Sorry to hear that.

      please suggest how I can treat further to solve my back and neck pain problem. You can do these exercises here. https://www.bodiempowerment.com/herniated-disc-part-2-the-best-exercises-for-your-herniated-disc/

      Which Dr will help me in this problem (orthopaedic/neurologist/rheumatologist…etc): If you are getting surgery then an orthopaedic surgeon or neurosurgeon are helpful. However, a neurologist is not a surgeon so will give you a less biased opinion.

      Will Acupuncture help to reduce back pain ? Acupuncture is most helpful most of the time.

      shall I use back-belt? No, you shouldn’t use a back belt as it will weaken your back.

      The above are opinions and not a recommendation. Hope that helps your disc herniation.

  • SHAILENDRA says:
    February 5, 2018 at 4:19 pm

    Sir, while putting a heavy weight on floor a sudden sound come from my back like charr and I felt pain at lower back which increases gradually day by day and it increases while doing activity like walking, sitting and bending by taking medicine pain decreases but start doing activity it comes back,my MRI findings are 1-lumbosacral transitional vertebrae with lumbarization of S1 vertebra.
    2-loss of posterior concavity of L4-5 disc suggestive of early disc bulge seen.
    3-mild diffuse L5-S1 inter vertebral disc bulge with propensity toward right causing mild narrowing of bilateral neural foramen (right>left) and abutting/mildly impinging bilateral L5 existing nerve roots more on right side.sir please tell me is it serious and about do’s and don’ts.

    • Dr Ken Nakamura says:
      February 28, 2018 at 6:07 pm

      Thanks for your question Shalidenra. The problem is you were born with a “transitional vertebrae with lumbarization of S1 vertebra” You normally have 5 vertebrae that are fused to form a sacrum. In your case, the S1 vertebrae did not fuse. In other words, you have an extra vertebra. This causes changes in your biomechanics so, this will require help from a professional that can examine you and take a proper history.

      Does it look serious? It doesn’t look too serious if you look at the disc. However, you have the complication of lumbarization which has the potential to slow progress.

      Do’s and don’ts? I can only tell you what people generally benefit from. Due to the changed mechanics of your spine the generalities may not apply to you. For example, it is best not to forward bend often or sit for long periods of time without getting up. Generally you should bend do extensions or cobra exercises. For the most part, you should do the exercises that I have here in this article.

      Hope that helps your disc herniation.

  • Dileep Gundapu says:
    February 1, 2018 at 1:07 pm

    Sir My self Dileep. G age of 20 years male. I have a problem means a lot of pain while speed walking and slow running also and suddenly collapsed and it occurs from above 5 months after that I went to a orthopaedic and I have scaned and in knee there is no problem after that I went to a Neurologist there I taken a MRI LUMBAR SPINE that gives a result of ” Mild disc bulges at L3-L4, L4-L5 With adequate Spinal canal and neural foramen”.

    Sir I have a pain at lower back and entire left leg and a small pain at right leg.I took a medicine for a past 15 days and there is no complete relief. It gives a few hours relief and pain comes back. Please give me a suitable suggestions. In a mean while a, have a small pain at hands also. Please give me suggestions sir.

    In 2013 I’m caused by a back pain and there it was a Bone TB and used a medicine for above 18 months. Sir is there any effect from that to this one. Please clarify my Doubts and give me a better suggestions.

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