Advice on disc protrusion

[alophysio]

Hi Sonj,

Thanks for the update.

Firstly, I know that you that you aren't after a diagnosis but some of the following might help those who read your story and do want some informatino ona diagnosis...again, i appreciate the fact that you have kept us updated.

SIJ as the first reason why your L5 disc may have been affected is definitely a possibility. The SIJ dysfunction can cause altered load transfer from the lower limbs thru the pelvis and into the trunk. The disc at L5/S1 then cops it and the stress gets moved further up the chain (spine).

That said, the current pain is still possibly from the disc. Whether your nerve is compressed or not is not too big a deal (believe it or not!). It is when the nerve gets sensitised that it causes pain.

I am not saying that nerve compression is not dangerous or serious, it is just a fact that there are people walking around today without ever having back pain who have nerve compressions. The noxious nature of the disc sensitises the nerve to physical stimuli.

To differentiate between the two, a compressed nerve should show signs of:
1. decreased reflexes for that nerve root
2. decreased muscle power for that nerve root
3. Altered sensation for that nerve root

Other important questions to ask is if you have had any changes in bladder or bowel function, sexual function or any numbness in the genital region. This is a sign of cauda equina compresison

The steroid injection has a postulated mechanism of helping resolve the initial stages of the inflammatory process to facilitate the resorption of the disc. This won't happen immediately but over the next 2 months following the injection, it should help. It has been some time now but i am assuming that the recurrent flare ups are like an acute injury

It has also been shown that an acute episode of pain in the L/S can cause unilateral segmental multifidus atrophy and is prognostic for further back pain episodes. My advice on this area is that you find someone who is skilled at training your multifidus and transversus abdominis. Preferably with an Ultrasound.

I don't think i mentioned that the treatment for a sensitised nerve is different for a compressed nerve. Make sure whoever treats you knows the differrence.

Lastly, You do have a chronic condition in that the pain has been there for more than 3 months. There are central changes - these are changes that happen at the spinal cord and brain level - that can make things difficult. In these people, pain can persist even after the offending lesion has changed/reomved/etc. Now obviously there may be a very big physical reason for your pain at the moment but even if you have it reomved, the pain be persistent. The current popular treatment for centrally mediated pain is called Cognative Behavioural Therapy. You may have to look into it eventually.

Anyway, all the best for what is going on. I hope things improve for you. Please keep us informed on how you are going. No doubt your story will resonate with a lot of the back pain population!!

[gogo girl]

what country do you live in? you describe a typical picture of disc protrusion and it sounds like it is resolving somewhat. Perhaps it would be helpful if you found a physio who can assess you correctly and advise on the correct/appropriate exercises

At this stage you may need some motor retraining (of the muscles) as the pain will have affected the way your muscles are firing and therefore not supporting or stabilising your spine well enough. this seems to be what is happening when you start walking over rough ground or downhill - possibly not sufficient stability leading to pain

I always warn my cients that they may think some of the exercises i prescribe for them are a bit woosy but they are needed to retrain the function (or even get them activating correctly) before strengthening and building endurance.

In my experience, Cortisone can be (1) helpful, (2) not make any change or (3) can make the problem worse. occasionally it "fixes " the pain for a signifiicant time but often the pain comes back if nothing else is done and repeated C injections have less effect and the relief period is shorter. there is some controversy as to how many one can have - one school says as many as make you comfortable, others say the minimum number due to side effects and/or damage to tissue. there have been promising studies done on animals where they have shown therapeutic ultrasound hastens healing whilst cortisone delays healing.

If a physio near you has an ATM2, this may be of benefit to you to - it is a machine whish fixes the pelvis and allows pain free movement.

A disc protrusion usually results from a damaged disc but significant studies show thta exercise can help if given and practiced correctly - good luck! If you have no pain, loss of reflexes or numbness you could hold off the surgery until you try a course of appropriate exercise

[Sonj]

Hi there.

I def have symptoms of nerve root compression esp the altered sensation. I used to get pins and needles and numbness alot, also pins and needles in groin area but that resolved itself. No change it bladder/bowel function though I did have a fright a few months back when I had the sensation of a full bladder but unable to urinate and had to sit for around 5mins or so before bladder would empty. This was put down to the codeine and also due to the fact that I was getting constipated, again due to the codeine. I now make sure I drink plenty water and this is all ok now. Re the altered sensation, my foot still goes numb and I get an odd thing happening when I walk sometimes. It's very weird. Normally you don't have to think about moving your leg yeah, you just do it. Well sometimes it was like it took all my concentration and will to be able to move my leg to walk. It wasn't paralysis as I could feel my leg no problem and it did move no problem,it was just that I had to conciously really think to move it. Most odd feeling. The chiro explained why that happened and it made sense, can't remember exactly what he said but it was something to do with the different kind of sensory nerve cells being effected. I also have muscle weakness in my foot and I did lose my ankle reflex at one point but it seemed to come back again and I did wonder if the Doctor who tested my reflexes at that point was just not very good at finding them because the Chiro was able to get it straight away.

Yes, the recurring flare ups are acute in nature and always seem to occur a few days after over exerting myself or walking downhill. Suggests to me that this is due to inflammation and swelling building up over the course of 2-4 days as the flare ups never occur until after a few days of over activity.

The Chiro has said that the SI problem needs to be sorted or else the disc problems and other back problems will keep reoccuring. He also said that I have a slight lumbar lordosis. Funny that cos I always wondered about my shape as my bum always seems to stick out too much and my belly is always protruding too much also (and it's not fat cos I'm slim!!) He also said that my upper spine was flatter than it should be. I think the main aim of his treatment is to get my spine and pelvis moving properly and to alter the shape of my back. Certainly, my back looks different to me when I look at it in the mirror. He says that I have problems which won't be corrected overnight. With you saying that the treatment is different for nerve compression and nerve sensitisation I wonder if the Chiro has been treating me differently as I had told him that the nerve was NOT compressed as that is what my GP had said to me.

Re Neuro Linguistic Programming, it is something I've heard of, sound interesting and my mother has just bought a CD about it as she is very interested in finding out more about it to help her, as she has Fibromyalgia.

Multifudis is the deep muscle in the back right? When I used to do Pilates I just bought a pilates video and did that and it seem to help my core but I do wonder if I didn't do things properly and possibly set myself up for future trouble. The Pilates type breathing that you have to do, I find very difficult. The Chiro has given me a static abdominal exercise to do. Hard to explain but you pull in the muscle just above the pubic area but you don't hold your breath but keep breathing in and out whilst just pulling in the muscle here. And you feel a tightning there and also a tightnigh in the mid back. He felt that I wasn't ready for any non static abdominal exercises. But for the past week I've been doing Pilates type sit ups where you flex your knees and hips at 90degrees and just lift your upper back slightly off the floor and it is causing no pain to my back or down leg but maybe I should stop cos there is always the possibility that I'm not doing it correctly.

I would like to go back to see a Private Physio but at the moment I just can't afford it as I'm not working. The Chiro is giving me treatment at a reduced price as I'm unemployed and I have a membership to a Health Trust which pays for half of the treatment. But yes, I'm quite worried that if I did decide to go for surgery that it wouldn't resolve my pain but at this point I do feel like I'm running out of options. As for the Cortisone injection I'm only going to get one. I'm of the school of thought that thinks that too many can weaken joints in the long term. And I do also believe that inflammation is part of the healing process and shouldn't be supressed but I'm getting to the point where I'm desperate to get my life back!

PS - I'm in Angus area in Scotland.

[alophysio]

Hi,

Just briefly...

1. one cortisone injection won't hurt (except the risk of infection because it is piercing the skin etc etc). Just make sure it gets done under fluroscopy

2. You have chronic low back pain. I don't think anyone would dispute that. The evidence is in favour of an active rehabilitation model. It sounds like your chiro is on track. You need to get MOVING.

3. If it doesn't hurt, don't worry. If you have been doing the back exercise for a week now and it doesn't hurt, keep going.

4. The worst thing you can do is decrease your activity. You should know your limits by now - do as much as you can without aggravating the back.

5. www.back-exercises.com has a good explanation on stability. Don't have to buy their stuff ok! It is for knowledge about stability etc.

6. At this stage, repeated manipulations won't help. You have had the chiro for some time now and your problem still exists. I wouldn't worry about him treating you differently - he sounds good and will have noted the compression signs anyway - and yes, physios and chiros are usually much better at reflex testing than doctors!

7. Get active, get active, get active. Just need to do it with caution. It is called "pacing".

Hope this helps. I would definitely see the surgeon though. All those pain and nerve signs are not good.

[Sonj]

Fascinating stuff, thanks for the link. As for keeping active, I think my main danger has been that I keep trying to be too active rather than under active. I've not been very good at pacing myself and have a tendency to do too much too soon. And also a tendency to keep on going and pushing through pain.

It's highly possible that my 'outer' muscles are overcompensating. Certainly when I do high load stuff such as the walking down hill I can feel my superficial muscles tightening up esp a band of muscle running down my mid and lower spine and in my bum and thigh.

[sdkashif]

Apart from the advice that you have taken from a number of contributors on your case discussion, let me add further. Please, also start a course of endurance training like using the stationary bicycling to do the aerobic exercise will increase your stamina and will do your cardiovasular conditioning improving the performance of your musculoskeletal system. That helps a lot in chronic pain states. For bladder problems, if there is any muscles weakness, it is better to strengthen the pelvic floor muscles. You must do the execises for pelvic floor muscles. Please, consult a urologist if the bladder and bowl problems worsen. In addition, you must try the spinal traction procedures and they have certain efficacy regarding pain and root compression symptoms. Let me tell you the detail of spinal traction as under so that you may get these session from your local clinician or physiotherapist there. Have a look on the over view upon the spinal traction procedures.
Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.
Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.
The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:

In lumbar spine a minimum friction free force of half the body weight is necessary for mechanical separation. Some authorities suggest that 1/3 of the body weight should be used for lumbar traction. While some suggests that 60 percent of the body weight should be used for lumbar traction. Generally lumbar traction should be applied in range of 18 to 45KG. To avoid treatment soreness, the first treatment should not exceed half the patient weight. Progression of dosage at succeeding treatment will depend upon the goals and patient’s reaction.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.

Have a look over a very useful article on Lumbar Traction.

http://www.thesaundersgroup.com/lumbar.pdf

I think that it will be of help to you. Please feel free to discuss more ideas or views in this regard.

[alophysio]

Hi Sonj,

Good advice above from sdkashif.

As much as i hate traction, this is one circumstance that i would use it.

Now, about keeping active - and you said it yourself - the problem is NOT keeping too active, the problem is that you don't know how to pace.

Pacing is simple. Start with walking 5 mins. That should be non-threatening for you. Then increase it s l o w l y.

Can do the same for other activities. Like you said, pacing is the problem.

And don't worry. Things will settle down.

I had a patient who strained his back at the gym. He felt it whenever he FF and did a certain move to stress it.

Anyway, we diagnosed the problem, outlined the solution and gave him the right exercises etc and sent him off.

We reviewed him 2 weeks later and found that the pain was just the same. He was doing his exercises properly. He had eased back at the gym, he was doing everything technically perfect but he STILL had the pain.

I personally was baffled so i asked him what he had been doing in his every day life, work, school, etc. After a while, he told me that he tested the back every 15-30 mins to see how it was going! In other words, he kept straining it to pain!

Needless to say, when i got him to stop that, he got better within the next 2 weeks. I wouldn't let him test it for at least a week!

The moral of the story is that once you stop aggravating your back, the pain will start to get better. Learn to pace yourself to give yourself the best chance. It is much better to stay active. If you become less active, you will become even more deconditioned and lose muscle mass and mke things worse.

Hope it helps...

[Sonj]

Hi first of all I can't afford to go back to a private physio for traction and it's not something that was offered to me on the NHS. I did try hanging off a pull up bar (and I know that's not the same) but it was too painful.

Re the walking, 5mins is nowhere near enough!! I could walk all day with no problems whatsoever but walking downhill is the killer. Before this injury I was used to walking out in the hills, carrying heavy weights for 10-12hrs in extreme weather! So 5mins is nothing for me even in my injured state. I try to test myself every so often as if I don't then how am I to guage how my recovery is going? But ANYTHING I do that causes compression, causes pain. Even when I tried to stay away from climbing and hillwalking and just concentrating on light walking and my stretching, the pain would still flare up from time to time.

Went for the steroid jab yesterday and great so far. Pretty much no pain left and even managed to sleep all night long, it was heavenly bliss!! So, now I just wait for the analgesic they injected to wear off and the steroid to kick in to see if it will help. If not I am going for the surgery as from what I can gather I could spend years trying various different therapies and get limited results.

[alophysio]

Fair enough.

I hope it all goes well for you.

maybe try the nhs again?

I think you have the answers - it is a matter of doing what is required. How? I don't know.

Again, it is hard to give advice without seeing you.

Let us know how things are going.

Thanks for the updates

[Sonj]

Hi, thankyou for all your replies.

Think I forgot to mention above that my GP had read out my results wrong from his PC. I went to see the Ortho consultant about my results before I had the injection. He said there is a large protrusion and it is def compressing the nerve root, quite badly infact! There is also some acute endplate something or other. He said that basically the way the disc was displaced it was nudging against the end plate and denting it. He said he wanted to operate. My chiropracter knows the consultant and says he's one of the best and he actually turns away over a third of people and sends them back to their GP without operating, so only operates when he deems it 100% necessary. The chiro also said that there is a high success rate with surgery where the disc protrusion protrudes into the lateral recess (I'm sure he said recess, but it was def lateral something or other) but conversely a low success rate with the steroid injections. 3 days now and the analgesic they injected into my spine is starting to wear off, so waiting to see if the steroid kicks in and helps now.

Thanks everyone for all your replies.

[Sonj]

Well, I took a very bad reaction to the steroid injection. The Thursday after the jab, my leg gave way and I collapsed in a heap of screaming pain and couldn't move for around 15mins and have been in worse pain than before the injection ever since. Then at the weekend after the injection, I had a full on panic attack which was abs terrifying. My GP told me, that some people react badly (though it is rare) to the steroid causing mood changes etc and this was made worse by the fact that I'm taking Amytriptyline. Would have been nice to have told of the possibility of this beforehand!! I'm still getting palpatations but the anxiety levels have dropped thanks to the use of herbal preperations of Valerian and Passiflora. Interestingly, now that I'm not taking 50mg of the Amytriptyline, I'm sleeping much better!!! My appointment with the Ortho has been moved forward to this Thurs and it looks like I will be having the operation.

Thanks for all the interest and replies to this thread.

[MrPhysio+]

Hi all,
Very interesting reading, and good histories. The problem with scanning over the years is that as scan resolutions become better, more 'problems' are discovered. Recent evidence indicates that between 67% & 75% of people aged between 30 - 80 years of age will have degenerative changes evident on scanning. These changes include disc bulges and spinal cord / nerve root compressions. What is even more interesting is that mild to moderate degenerative changes can be completely symptom free, also including spinal stenosis, nerve compressions.
Therefore a person may have had a disc disruption / compression for years without knowing, hurt their back in another way, have a scan, and find out information that is completely useless to the current new problem. This explains why many treatments, including surgery. Therapists are trying to fix something that is not broken.

Forgive the simplicity of this next suggestion, but I believe that the majority of your symptoms can be explained by a tethering of your piriformis muscle to your sciatic nerve. Stretches can sometimes improve this condition, but can also worsen the irritation. Your sciatica is explained by tethering, as are the exercise induced symptoms, as well as the problem caused by sitting.Lumbar muscle spasms are due to the erector spinae muscles spasming or tightening to act as a splint, which then decreases your mobility further, and increases compression forces.

I believe that you need a very deep piriformis friction massage, then gluteal / sciatic exercises over two days. If the treatment is not firm enough, it will fail. Your previous history of severe pain in the gluteals should not preclude this deep type of treatment, but it will hurt!
I carry out such treatments all the time, and they are safe, and usually unmask the nature of symptoms, and often provide information as to whether tethering or the disc is the major contributing factor to the pain.
As other writers have suggested, you are now in the chronic pain category, therefore compensatory changes will have occurred with the failed treatments and time eg further tethering, muscle imbalances.

As you cannot readily access your physio, you could try the following:
1. To find the correct area, place your little finger on the top portion of the gluteal cleft, and your thumb of the same hand onto your greater trochanter
(bump on your upper thigh bone).
2. A third of the way between your little finger and thumb is likely to be a tender point.
3. Find the sharp edge of a cupboard or table top, and back your buttock onto the sore area very firly, to the point of deep pain.
4. Do the same thing 25 mm (1 inch) above and below the first point, on a curve. The areas are probably sore.
5. Do a stretch either in standing or laying down, where you pull the affected side knee towards the opposite shoulder, hold the stretch without bouncing, for 15 seconds. Repeat 10 times, 3 to 4 times daily.
6. Do a hamstring stretch for the affected side with the same directions as for the gluteals.Do not bounce any stretches - have a sustained hold to the point of discomfort, not pain.
7. Morning and night lay on your back, knees bent,with your heel a comfortable distance from your buttocks, knees and ankles pressed together, and rock your knees gently side to side for 5 minutes, not into pain.

Do the above exercises for at least 2 days, even if the buttocks are sore. The pressure against the table top edge can be sufficient to cause bruising, if done correctly. If you do not do the exercises, the treatment is a waste of time, as is a gentle treatment.
Do not increase your daily activity levels within the first two days, no matter how much better you feel.

Note, if any of the exercises cause increased true neural signs such as loss of strength, or numbness beyond what you already experience, decrease the intensity of the hamstring stretches.This is unlikely if you take the exercises gently. The friction massage for the priformis cannot worsen any spinal stenosis, and is therefore safe.

Hope the above helps. It is certainly worth a try, especially as surgery is being viewed as an option.Do not sit for greater than 20 minutes for the first two days, without doing glteal stretches (one for 15 seconds), or better still walk a little (couple of minutes change of position).
Goodluck
MrPhysio+