Advice on disc protrusion

[Sonj]

Thankyou for the reply.

To be honest, I'm not really after any diagnosis of problem, or advise on problem as such, it was more that I was wondering what would happen to the disc itself. But if there is evidence that protrusions can go back into place then this is good.

Am not sure, but am assuming that as it is a protrusion I have, and not an extrusion, then the NP will be contained and not able to cause irritation to nerve. But the stabbing pains in bum and leg were def caused by something irritating the nerve/root, wether from the protrusion itself which has now started to 'go back into place' or wether due to irratation from surrounding structures, ie tight muscles etc, I am unsure.

After a week now of doing my stretches the pain relief is astounding!!! And I managed a 45minute drive yesterday with no painkillers needed and no flare up of symptoms which is a great improvement.

The Chiro did advise that I start stretching the piriformis and gluteal muscles, he just didn't advise me what exercises to do, but in his defence, I had a muddle with my appointment time that day and he just managed to squeeze me in as he is very busy, and perhaps there wasn't time for him to go over which exercises I should do. He did say, that any I do should cause a stretching type feeling in the muscle but should cause no pain to my back or SI. The stretches I am doing are just ones that I found on the internet. For the past couple of days I have now managed to try doing some back extensions and can manage them now pain free, but not full extension, just partly.

I tried to sit again last night on a firm chair with good posture and back support, but after 5mins the pressure became too much so I had to get up and had pain down to knee. Coughing used to be painful but is now just more uncomfortable. Sneezing is evil, LOL!! I have to brace myself for the stab of pain that it will cause. Stab of pain is in the sacral area. Infact majority of pain is around here I think, it is hard to tell at times, as the pain is deep. I feel no pain whatsoever in the L5 area, just a slight bruised kind of feeling if I push into that area with my fingers.

I agree that 5months seems a long time for treatment, but I do feel loathe to part with the Chiro as he has helped ALOT, even if there is not much focus on my muscles. And I have to admit, that over the course of seeing him, I havn't always heeded his advice. He has told me that I can continue climbing (he is a climber himself, and understands the physiology of climbing) but that I must be very aware and careful of how I move. Climbing involves certain moves to scale up the rock or wall face. Now, he has advised that I keep my moves small and fluid, avoiding any jerky moves, any lunging and scrunched up movements, or any high steps with the affected leg, bearing weight onto this leg. Basically any type of movement which compresses my back. This is why the hillwalking is so bad just now, as the downhill walking, causes too much compression. If I climb in the manner advised then all is fine, but I have often found myself pushing it, and going for harder moves, which result in flare up of pain. I have subsequently been going climbing less as pushing myself in my sport is one of the joys of climbing and I soon become bored doing easy moves. I am thinking that the time length of my recovery is due to my own fault in pushing myself too much, rather than anything the Chiro does, or doesn't do. Also, as I am lacking in sleep, I have become somewhat run down, and have had the flu twice in the past 5months, coming from rarely ever having any infections of any sort. The flu, both times put me to bed, and unable to exercise, and this, with all the coughing and sneezing at the time, made things flare up badly and set me back. I think I will continue with the Chiro for the time being but if my condition does not improve in the next couple of months then I shall research this 'Motor Control Training'. Thanks for the tip, re that.

Yes, I get more hamstring length with plantar flexion. SLR used to cause a violent stabbing sciatic like pain, but now just causes a tight, stretching type pain in bum, hard to pinpoint from where exactly.

Anyway, thanks again for the reply and like I said, I was more just curious as to what was going to happen to my disc. And I have many queries for the Ortho in a couple of weeks and for my next appointment at the chiro, just impatient for the answer I guess.

[alophysio]

Hi Sonj,

Your irritated nerve root is sensitised by the nucleus pulposus - apparently the chemicals can exit via fissures in the disc. It is unlikely that the bulge itself is the cause of the irritated nerve root because it has been shown that asymptomatic people can have apparent bulges onto nerve roots without pain. Mechanical stimulation of the nerve root is also fairly benign but when it is sensitised, this is when problems occur.

As for resorption of the disc, it will need to be transligamentous to occur. Now a protrusion can be transligamentous just like a gloved finger can go thru cling wrap. Once past the PLL, an inflammatory process occurs which begins the process of resorption..

I am glad to hear you are doing well. You will now have first hand knowledge of why listening to your therapist will be something your patients will have to learn to do!!! As they say in the classics..."Physician heal thyself!".

As for the motor control thing...There is no reason why you can't research it now and use it to complement your treatment from the chiro. It sounds like your chiro is doing a good job and giving the right advice but you still have pain on sneezing 5 months down the track. This seems to indicate to me that you are unable to control the intraabdominal pressure generated during the sneeze. An intact "core" or "inner unit" or "local system" is required to help in this area. Developing your coordination and endurance in your "core" ill help dissipate the forces generated. At present when you sneeze, the force is being sent thru the weakest part of you abdominal cavity - the injured disc.

In my honest opinion, waiting to see if just the good chiro treatment alone will help this problem before trying the exercises seems to be like saying "I will learn to kick a football with my left leg after i have mastered scoring goals with my right". You can get away with just having chiro treatment but wouldn't your body appreciate the extra help that the exercises will give you?

Anyway, I think your chiro sounds like what a good physio should be doing for you. They have really started to embrace the whole rehab side of things and if we as physios don't stay on our toes, we will become obsolete.

Good luck and let us know what the doc says - please note he is an orthopaedic SURGEON so by definition he prefers to cut. If you are not a "cutting case", he may not be interested in you, especially if his waiting list is 3 months long!

[Sonj]

Thankyou again for your thorough reply.

Yes, the Chiro seems very good. I must admit to being very hesitant in seeing him at first as I had heard alot of bad stories of chiropracters previously along with some good stories too of course. And this one was recommended to me by several people who had suffered from back problems. Seems to be that just about every one either has had or knows someone who has had a back problem.

I understood that some folk could have a protrusion and have no symptoms but didn't realise that it could press on nerve and there be no pain. The private physio that I originally saw did say that it was very sensitised. At the beginning the pain seemed to be very 'exagerated' ie - one time my friend just barely touched my hip and it sent me into spasms of agony, she was quite bemused as she had really just brushed past me nothing more, lol!

I take it by resorption, you mean the disc protrusion going back into place as it were, as opposed to reabsorption, where perhaps the disc degenerates and is reabsorbed by the body???

Aye, guess it will do no harm to research the Motor Control thing just now. I have never heard of it before, hopefully there will be someone in Scotland, nearby who practises this!

Yes, my core is pretty weak just now. I used to do alot of pilates, as core strength is very important to climbing to keep you close to the wall when on steep or overhanging ground. The pilates was really helping there, but then I got lazy and out of the habit of doing it so regularly. I hadn't done any core exercises for around a year before my disc going and I do wonder if this, along with the very heavy weights you have to carry when winter climbing in Scotland and the often very steep ground you have to cover, contributed to my disc going in the 1st place.

As for the surgeon, the Chiro knows him and says he values his opinion greatly as he is very good. He says he is not 'scissor happy' as it were, and will not choose to operate unless it is 100% necessary and as there is no nerve root compression and I am alot better, I am confident I shall escape his knife! Hopefully he will not be too brusque with me, as many ortho's can be, having had experience of them after breaking my wrist a few years back. Ended up with extensor tendinitis which physio cured a treat and made me develop an interest in it. The human body, muscular and neurological is such a fascinating and complex subject. How one disorder in some part of the body, can effect a multitude of different parts elsewhere, so much to learn........

I also had an appointment at a pain clinic recently, where I had a loan of a TENS machine. Found it helpful but a real hassle to use and the electrodes didn't seem to stick well to my skin, so I gave up on it. The pain specialist I saw also does Acupuncture and has booked me in for a course of that, but my appointments aren't until June (blasted NHS waiting times!) and I'm hoping that I will be all better by then!!! She has also made an appointment for me to see about having an epidural, which I am none too sure about. I detest taking drugs of any kind and it was months before I had to relent and start taking painkillers, the physio I was seeing said she had never had a patient not take painkillers for nerve pain before, and I should not be so stoical, hehe! So the thought of pumping drugs into my spine, does make me shudder somewhat. And I have heard stories of steroid injections weaking joints in the long term, wether this is true or not though, I do not know. That was another thing, she prescribed me Amytriptyline to see if it would help me to sleep better and said I would probably need to work my way up to 50g a night before it would be effective for pain relief. I have been on 50mg for the past week now, and I'm wondering if it is this or the exercises and stretches I am doing that is giving me relief, or a mix of both. I'm highly tempted to stop taking the Amytriptyline to see if the pain comes back as it is making no difference whatsoever in helping me get a good nights sleep and that's why I was willing to try it in the 1st place.

Aye, I will post again once I have seen the Ortho and let you know how I got on. Thanks again

[sdkashif]

According to Melzack and wall depression has been mentioned as a concomitant of chronic pain and it is therefore natural that many types of antidepressant drugs should be prescribed. They help the patient natural depression but they also sometimes have a surpringly powerful effect on pain which appears to be independent of their action on the depression. These drugs act by increasing the concentration in brain and spinal cord of the amine transmitters such serotonin. These amines are thought to play a role in inhibitory mechanisms, especially the descending controls. It may therefore be that the antidepressant drugs have a double action, one to help depression and one to increase the effectiveness of existing inhibatory mechanisms. So it is a possibility that you may getting the benefit of analgesia by antidepressant amytriptyline. Although the exercises have also a role in pain relief as aerobic exercises are thought to increase the endogenous opioids resulting in the pain relief.

[Sonj]

Hi there.

Yes, I finally succumbed to trying Amytriptyline a couple of months ago. I have always been able to 'grit my teeth' and just get on with things regardless of the pain, only using codeine when really bad, or during the night. But I thought the Amytriptyline might help me sleep better. So far it has been of no help whatsoever for sleep. Taking codeine before bedtime, I can fall asleep fine, the problem is that I wake a couple of hours later in pain and then have to wait an hour or so before I can take more painkillers because of the paracetemol. Last night I got just over 3hrs sleep, yawn!! I have tried Tramadol also but found it useless and all it did was make me feel like a zombie.

It actually dawned on me last night that the therapist at the pain clinic said I would need to work up to 50mg of the Amytriptyline before I found any pain relief from it. Now, I have been on 50mg for a couple of weeks now and it crossed my mind that perhaps I have been feeling alot less pain over the past week due to the Amytriptyline rather than the stretches I am doing, or perhaps a mix of both. I am curious to know which it is that is helping so I stopped taking the Amytriptyline last night. It will be interesting to see if there is a return of worse pain or not. If there isn't then I won't be taking it any more, as it does nothing whatsoever in helping me sleep through the night.