Herniated discs are a very common source of very difficult neck and back pain. Herniated discs are also the endpoint of a prolonged process of degeneration. Most herniated discs do not happen as a result of a single acute trauma. They typically happen as the end result of a small trauma, superimposed upon pre-existing degenerative changes to that disc. The aggregating, degenerative changes, make the disc vulnerable to a final small trauma, which can result in the final herniation of that disc.
As background, you should know that the spinal disc, which exists between each of two consecutive vertebrae, above and below, is made up of 12 to 25 tough, fibrous, concentric layers of connective tissue that encircle and enclose a central gelatinous component. The outer layers are called the anulus fibrosus. The inner component is called the nucleus pulposus. The central component, which is actually more like the consistency of crabmeat, is often described as a gelatinous-like center.
The axial loads, meaning the weight loads of your body weight and the weight of your head and spine and trunk when you are upright, push down on the central component of the disc, which then pushes outwards against the outer layers of the disc.
Over time, beginning in childhood, the inner-most layers of the encircling, outer layers of disc begin to tear, and these tears accumulate and extend from the inner part of the disc, and radiate out, toward the outer part of the disc. Early in the process, there is no perceived pain from this degenerating process because there is no nerve supply to the inner part of the disc. As a result, children and teenagers become accustomed to doing things with their bodies that are injurious and yet they don’t feel it, so they don’t learn the sorts of activities that are injurious to a disc. That means that when we’re younger we learn to do injurious things without learning that they’re bad, and we continue to do those activities until we become injured to the point of pain, i.e. symptomatic, typically in early or later adulthood. Sometimes the eventual herniation happens as a result of a very simple physical demand such as prolonged sitting, or sitting on the floor, or bending over for a prolonged period of time, or even bending over just once. When this happens it may seem particularly odd, because we’re so accustomed to doing these things without any pain. But it is the understanding of the long, antecedent history of quiescent disc degeneration that provides a true understanding for this process.
We define the eventual disc herniation as the extension of disc material beyond the borders of the vertebrae above or below. This disc herniation may include several types of tissue, including the outer anular fibers, the inner nuclear fibers, the cartilage endplate, or even bony components.
Thankfully, the natural history of disc herniations is to get better with time. There are many people who experience disc herniations that are small and resolve on their own, without the necessity of treatment. On the other hand, it is also true, that disc herniations can be extremely painful and persist in provoking pain for many years. Disc herniations can be inferred from the person’s history of pain, including the distribution of pain, as well as from MRI imaging. Disc herniations typically give rise to pain that extends down the arm or down the leg. Herniated discs, as a source of pain must be distinguished from what we call referred pain. Referred pain is a certain distribution of pain in your neck or shoulder or back or leg that is caused by a less extensive problem of the disc, that does not radiate pain as far as a herniated disc typically does.
The way most providers treat disc herniations, almost all of the time, is with a trial of conservative, i.e. non-surgical treatment first. This could include exercises or chiropractic adjustments or pain relieving modalities. In my 29 years clinical experience in orthopedics, physical medicine, physical therapy, chiropractic and neurosurgery, I have found spinal decompression treatment, such as I have provided for the last nine years, to be the most clinically effective means of improving disc herniations without the need for surgery. There are occasions, probably about 5% of the time, when I need to refer people for epidural steroid injections because I can’t help them sufficiently. This is much less frequently than most doctors, because I provide a more effective nonsurgical alternative in the way of spinal decompression treatment. Of course, there are occasions when I refer people for surgery as well. The objective of all providers should be to provide the best nonsurgical alternatives to try to avoid surgery. Every provider pays this objective lip service, but most don’t provide spinal decompression treatment, which in my experience is the most effective alternative. Absent the use of this alternative, many more people will end up getting injections and surgical treatment. The rationale for pain management, i.e. epidural steroid injections is to provide an injection of corticosteroids near the site of the pinched nerve, or inflamed tissue, to reduce the inflammatory component of the pain. If this doesn’t suffice, surgery may be necessary.
There is a tiny, rare subset of patients with disc herniations, which causes a rare entity called cauda equina syndrome, which requires immediate surgery. Cauda equina syndrome involves severe, progressive loss of motor function and may involve loss of bowel and bladder control. This is a rare, complication of disc herniation- usually a massive herniation, which requires immediate surgical decompression of the nerve root so as to protect the nerve function for the future. Thankfully, this is a very rare entity, occurring in less than 1% of disc herniations.