Intervertebral disc injuries include Herniated discs and Annular tears.
Herniated Nucleus Pulposus
Definition - this injury is also known as just a herniated disc. Often this is referred to as “slipped disc” but this is an incorrect term as the disc itself doesn’t actually slip.
A herniated nucleus pulposus occurs when the nucleus of the intervertebral disc bulges into the annulus causing a herniation. There are 3 levels of herniation known as prolapse, extrusion and sequestration.
Prolapse – this is the most mild form of herniation and is a partial rupture of the annulus.
Extrusion – occurs when the nucleus breaks through the outer wall of the annulus and into the spinal cord.
Sequestration – this is a complete tear of the annulus and involves portions of the annulus and the nucleus pulposus protruding outside the disc.
Annular Tear
The annulus is the outer surrounding of the intervertebral disc. This can be torn due to mechanical load on the spine. It is highly innervated and when torn can cause a lot of pain. If someone is said to have an annular tear then it usually means there is no herniation. If someone is said to have a herniated disc then an annular tear is most likely present also as this needs to be torn for the nucleus to protrude through.
Subjective
History (Hx) -
- Did the pain come on from a specific movement or was it gradual?
- Age?
- Exercise?
- Job?
- Overweight?
- Previous history of back pain?
Objective
Observation –
Looking for antalgic lean. Antalgia is when a client tries to lessen pain. This lean away from the painful side can indicate which is the painful side.
Palpation – Pain may be felt by client when pressing around the vertebra that is affected, especially the spinous process.
Range of motion and Resistive Tests –
Generally pain is increase on flexion so getting client to do this can be a sign of disc injury. Note that this can aggravate their back.
May be limited in flexion, extension and lateral flexion. Also all ROM may cause pain.
Special tests – to determine what is going on?
Straight leg raise test: This tests for herniated discs. Client in supine. Slowly raise their leg off table keeping it straight. Bring it up to around 70° (this is when sciatic nerve is fully stretched), if client feels symptoms worsen then this is a positive, reduce stretch to see if pain reduces. If negative test then have the client dorsiflex and then flex head and neck to increase stretch on nerves.
Slump Test: This also tests for herniated discs. Client is seated with arms clasped behind their back. Upper Thoracic is then flexed (not the whole back), followed by neck and head, then the affected leg is straightened and then the foot is dorsiflexed. Pain is a positive test. The symptoms should be felt where the injury is.
Valsalva maneuver or cough test – get the client to breathe in and bear down as if going to the toilet. Also have client take a deep breath in and the cough. If either of these test reproduce the pain then it is likely it is a disc injury as the extra pressure created with stress the discs.
Assessment
If the history and objective tests prove positive then it is likely there is a disc injury or irritation here.
Plan
If you feel that there is a disc injury present it is a good idea to get a Physio/Chiro/ Osteo or a GP on board to get a scan or to confirm findings.
Core and glute strengthening programs are effective at taking some pressure off the disc. This can be achieved through a Physio.
Treatment
Soft tissue massage to glutes, QL’s. piriformis, hip flexors and abdomen can take a lot of the pressure off the disc and give some relief. If the injury is mild then it may take away most of the pain. Regular treatment will be required to stop tension building back up.
Note that when massaging someone with a disc injury or potential disc injury you should always place a small pillow or towel under the pelvis to take some of the stress off the spine. Also don’t use too much pressure around the spine as this could put more pressure on the spinal discs. When client is supine have pillow under their knees.
Extension stretches are usually good but may also aggravate severe disc injuries. Treat case by case.
Strengthening exercises that target core and glutes will be needed.
Referral patterns for the lumbar vertebrae.
Differential Diagnosis
Piriformis Syndrome, Myofascial Trigger points, Bone spur, Spondylolysthesis, arthritis.
Special Needs
Disc injuries are very common as we age. Our discs are gradually becoming less fluid and drying out making them more susceptible to injury as they provide less cushioning and have been weakened and damaged throughout our lives.
The elderly will most likely have disc injuries so keep this in mind when treating especially for lumbar injuries.