Contrary to popular belief ‘Disc herniations’ are not the end of the world and an indication for bed rest and cautious movement for the rest of your life, nor are painful, or scary-sounding surgeries their only solution.
In an earlier blog, I’ve discussed why using the term “slip disc” is incorrect when talking about disc herniations, how it promotes the idea of our bodies being so fragile that a structure (intervertebral disc, in this case) would just pop out with little movement and how common it is to have such changes on MRI and no symptoms whatsoever.
The better news is that disc herniations do heal over time in a period of about 3-12 months. Lumbar disc herniation can regress or disappear spontaneously without surgical intervention. Moreover, most cases of disc herniation resolve within a few weeks after the onset of symptoms
Intervertebral disc herniations can be classified into prolapse, extrusion, and sequestration roughly.
Even though it might seem by looking at the image that the primary stage of herniation could be a prolapse leading to relatively lesser pain whereas an advanced or more severe stage could be sequestration causing relatively more pain, it would be incorrect to assume so.
The extent of disc herniation doesn’t correlate well with the amount of pain and the level of disability experienced by the person.
The pain experienced likely depends on the process by which the herniation occurs, if the herniation is sudden irrespective of whether it is a prolapse, extrusion, or sequestration, the person would probably experience a higher amount of pain as opposed to if the herniation occurs over a period of time which allows our body gradually adapts to the change occurring and doesn’t suspect it to be dangerous, not to forget the psychosocial factors in each case which would contribute to the same.
Karppinen et al in 2001 reported that “the degree of disc displacement in MRI did not correlate with sciatic symptoms.”
Nerves get pulled, compressed, and twisted all day long and we don’t notice.
Nerves are sensitive but strong structures. They tell us what’s going around in our bodies like a messenger. Ever sat for too long on your foot and experienced a funny yet uncomfortable vibration-like sensation that makes your foot feel heavy and hard to move but gets back to normal as soon you move around? Well, that’s your nerve getting compressed and sending you a signal to relieve that compression by moving.
Ever hit your elbow suddenly on a hard surface and experienced a shock-like sensation running down your arm, that’s your ulnar nerve getting hurt since it lies superficially.
Up until fairly recently, it was thought that sciatic pain due to herniation of the lumbar disc was caused by compression on the nerve root.
Recent studies have demonstrated how inflammatory products are released as a result of disc herniation which causes the products present in the IV disc, to come out leading to an inflammatory reaction and therefore pain.
These inflammatory products irritate the nerve making them sensitive to compression (compression here becomes an aggravating factor and not the cause) leading to the symptoms.
We can take sunburn as an example to explain the above mechanism. Staying too long in the sun without protection causes sunburn which makes our skin red, irritated, and painful, and when we take a shower, the water feels painful. So would we say that water is the cause of our pain? Of course not. The increased pain from the water isn’t due to more damage, just irritation of already sensitized tissues.
Likewise, when our disc herniates or bulges i.e. get displaced from their original location, it leads to the release of some inflammatory products which sensitize the tissue around causing pain that gets exaggerated by compression, it is like someone poking an already bruised area.
This goes on inside our bodies as well. We don’t see it doesn’t mean it’s not happening IRL.
Like any acute injury causes inflammation followed by eventual healing of the tissue the same way herniated discs heal too, most likely by a mechanism called resorption.
And it seems that the greater the amount of herniated disc the better the healing.
Why this is, is not fully understood and depends on individual factors but it may be due to the disc material being more exposed to the external environment making it easier for our inflammatory processes to digest and reabsorb it.
Systematic reviews by Chiu et al in 2015 and Zhong et al in 2017 show that discs can heal on their own over time.
Chiu et al. state, “Extrusion, sequestration type of herniation or herniation with migration have greater exposure into the epidural space than does protrusion, bulge-type herniation, or herniation without migration. As sequestrated herniation is isolated into the epidural space, inducing surrounding inflammation, it is not surprising that it has the highest rate of complete resolution.”
The authors of the above paper further conclude, “it is seen that the probability of spontaneous regression was 96% for disc sequestrations, 70% for extrusions, 41% for focal protrusions, and 13% for disc bulges.
The results showed the fact that the higher the grade of disc herniation type, the higher the rate of spontaneous regression.”
“There are many factors that can influence clinical outcomes besides the size of disc herniation, such as poor lumbosacral stability causing mechanical low back pain, chemical radiculitis, nerve root adhesion, and psychological factors as examples. Therefore the sole factor of “disc regression” cannot predict or be well correlated to better clinical outcomes. Conversely, it was observed that the clinical outcome can improve even WITHOUT disc size regression.”
In another systematic review and meta-analysis of cohort studies, 11 trials were selected which represented a total of 587 LDH patients managed conservatively, 380 of whom experienced resorption. The meta-analysis showed that the overall incidence of spontaneous resorption after LDH was 66.66%.
The authors of the study state “Conservative treatment could reduce complications, lighten the suffering, reduce the economic burden for patients, and elevate their quality of living.”
So is surgery the best option and do you need it right away? Most likely not.
If the cause of the pain and discomfort was merely the herniated disc compressing on the nerve root, it would make sense to just make an incision and extract the herniated disc thus relieving the compression, but as explained above it’s much more than just compression.
Sometimes people may have surgery but the pain may persist or may reappear after a while.
A paper by Peul et al (2007) and systematic review by Fernandez et al suggest that surgery might provide better short-term relief and faster recovery; but on average long-term outcomes between surgery and conservative management are similar, therefore conservative treatment should be preferred in most cases considering that surgery doesn’t guarantee a permanent fix, comes with its risk and cost, providing similar outcomes in one year as conservative treatment.
As the paper already explains, exercise isn’t only a treatment intervention but also provides a lot of additional physical and psychological benefits while being simple, cheap, and extremely safe.
However, it’s best to discuss with your medical doctor the choices of treatment available and the effectiveness of each.
Additionally, there is a high probability of resolution of pain irrespective of whether the disc heals or not.
In a study that included One hundred sixty-five consecutive patients, 114 males, and 51 females, with an average age of 41 years (range, 17-72) and an average duration of symptoms of 4.2 months (range, 1-72) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study.
Out of the 142 (84 were herniated discs, 27 bulging discs) were conservatively managed and rescanned.
The results state, “All patients rescanned were able to work and follow their usual leisure activities. The average improvement in their level of pain on the visual analog scale was 94% (range, 45-100%), and none had root tension signs. Seventy-four (67%) had neurologic signs on presentation initially, and of these, 70 (95%) had made a partial or complete recovery.”
The outcome of the study was as follows:
Pain can surely be terrifying and disabling but nothing is constant in life except for change. Mri’s are unreliable and pain can change with a little time and patience by allowing our body to heal and supporting it in the process of the same.
Start small and stay consistent, do whatever feels good which can be anything from taking a walk or doing some yoga to doing any movement that you enjoy, and gradually progress further, get proper sleep of at least 7 hours, drink plenty of water and eat nutritious food and take breaks to move around when sitting for long hours. There’s no movement that is inherently harmful and should be avoided at all costs, different movements can cause aggravation of pain in different individuals, so it is advisable to temporarily avoid those movements initially and steadily introduce them back.
Rehab doesn’t have to be complex and elaborate, the goal is to improve function and get back to doing things you like, there is no one protocol that fits all strategies and no single movement causes the disc to herniate, and neither can any movement/ person can push the iv disc back into place.
In conclusion:
Discs can heal.
We have no test currently that can identify the disc has the source of pain.
Cutting our part of the disc does not always change pain and symptoms.
Pain can go away whether the disc heals or not.
Don’t worry about the bulge, find what movement works for you and get moving.
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Cover Photo by Agung Pandit Wiguna
Disclaimer: In the presence of pain all the structures and context must be clinically assessed, this blog is in no way a substitute for a clinical assessment and all must consult a physiotherapist or a physician in such conditions.
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