Jun 19, 2017 by spinalcare
This is the second in a 2 part series on herniated discs. If you have not read Part 1 in last month’s post, it might be helpful to do so prior to starting Part 2.
Many people (doctors included) rush to get an MRI when there is back pain. (This rush to order imaging without proper exam first has subsequently made it very difficult to get the insurance companies to OK an MRI if/when there are true symptoms of a disc issue). If a disc herniation or bulge is found, they are quick to blame these easy scape goats, and in a worst-case scenario – rush to surgery. Herniations and bulges are an easy to see on films. The docs can easily show it to the patient who is eager to have a concrete “cause” to explain her pain. The problem is, as we have cited before, there are many people with disc herniations that are completely asymptomatic and have no pain.
According to Dean Boyer, journalist and author of Rebuild Your Back,
“To get the full story we have to go back about ten years to a study published in the New England Journal of Medicine involving the use of Magnetic Resonance Imaging (MRI) to diagnose back pain. In this study researchers (who were intrigued by the findings of several other studies concerning herniated discs) selected 98 subjects who did not have back pain or any other back related symptoms and sent them to be evaluated by MRI scans. What makes this interesting is that the evaluators were not told that these people did not have back problems.
The results were pretty astounding and sent a shock wave through the medical community at that time. What they found was that 64 percent of the test subjects came back with MRIs that showed disc problems that normally would have marked them as prime candidates for surgery except, of course, for one little problem and that was that they did not have back problems at all!” (1. 2.)
So why is it that some people with mild bulges have intense pain and some with severe protrusions have no pain? That’s where the doctor needs to do some more digging and get to the true pain generator. Too often disc herniations or bulges are blamed for pain. It’s a quick and easy answer that satisfies the patient and validates their pain. Most people are far more satisfied to hear they have a big disc herniation than a hip flexor/oblique strain, chronic inflammation, poor core development or bad postural habits. The irony is that any of these alternative sources of back pain can be intensely painful while herniations can be completely asymptomatic.
We see all too often in our office where a patient comes in and tells us that they have a herniated disc (or 2 or 3) and they suspect there is little we can do to help. They have resigned to the fact that surgery is the only option and come to see us only to appease a nagging spouse or well-meaning relative. More often than not, these patients walk out pain free after only a few visits. It only takes a digging a little deeper beyond a frightening image on a film. We all know of someone who has gone in for back surgery only to come out with no change – or worse – with more pain. That’s the price of assuming a herniation is the pain generator without looking farther.
People often assume if they have low back or neck pain, it must be a “slipped disc” (there is no such thing as a “slipped disc”. Discs cannot slip. This is a term commonly used to refer to a herniated or bulging disc). The fact is that most low back pain is soft tissue (muscle, tendon, fascia) based. A muscle spasm/strain can be some of the most intense pain anyone can experience. Think of labor pain. That’s a spasm of the uterus and most women rank that as the worst pain they have ever experienced. Imagine a leg cramp or Charlie horse. Then imagine it in an area with twice the muscle mass and a more central location that will not relent. That should give you an idea of the intensity of pain associated with muscle spasm. Acute muscle spasms and strains are often much more painful and debilitating than disc pain.
What about back or neck pain that travels into the legs or arms? That is definitely a sign of a disc issue!
Not always. While extremity pain can be a symptom of a disc herniation, it is not always the case. When a disc herniates, it can put pressure on a nearby nerve and cause pain and weakness into the legs (in the case of a lumbar disc) and into the arms (in the case of the discs in the neck), but that is not the only cause of this “radiating” pain. (see image below)
Often trigger points in the muscle and fascia refer pain to the buttocks, thighs, shoulders, calves and forearms. Bone spurs and arthritic conditions can also lead to radicular pain. Additionally, movement patterns that can cause back strains and spasms can also lead to similar issues in a leg or arm. What many patients think is pain from a lumbar disc radiating into the buttock is often a strain of the abdominal oblique and piriformis muscles. Again, the key to determining the cause of the radiating pain is a thorough examination that relies on movement analysis and neuWe are not saying that herniated discs are not a problem. They can be very painful and can lead to muscle weakness, loss of sensation and radiating pain. We just don’t want anyone rushing to a quick answer if it will not ultimately resolve the problem. When any pain lasts longer than 7-10 days and is not improving, it’s best to get checked out by a qualified practitioner. We at Spinal Care believe a conservative option (non -surgical) is always the best place to start. We do a thorough examination and if the issue is soft tissue based, we will treat it and get you back to living your life – usually in 4-5 visits. If the issue is a true disc herniation and more aggressive therapy is needed, then we can help you navigate that as well.
1Brinjikji, W., P. H. Luetmer, et al. “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.” American Journal of Neuroradiology 36.4 (2014): 811-16. Spine, 2015. Web. 4 May 2017.
3Steffens D, Hancock MJ, Maher CG, et al. Does magnetic resonance imaging predict future low back pain? A systematic review. Eur J Pain 2014;18:755–65
2Callaghan, J.P., and McGill, S.M. (2001) Intervertebral disc herniation: Studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics, 16(1): 28-37.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, et al: Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69-73.