Disc Injury - a guide

This guide is for patients who have low back or buttock pain caused by a painful or weak intervertebral disc.The disc can either be painful in its own right (because of damage to pain sensitive fibres of the back or side of the disc) or it can cause achy muscles (as the muscles of the low back work over hard to ‘protect’ the disc).

It can all be quite confusing...

It can all be quite confusing...

If your disc problem is also causing sciatica in the leg (i.e. you have sciatic pain or numbness or pins and needles in the upper or lower leg) this guide does still apply, but with modifications.

The type of patient who this guide applies to will likely be in the age range 30-55.

There are other more common causes of low back pain, particularly sore joints, muscles and even ligaments. These tend to resolve with proper care over a period of about two weeks, but because discs are slow to heal, particular care over a period of up to three months must be taken to avoid relapse and promote recovery, hence the need for the more detailed advice in this guide.

Anatomy

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The typical IV (inter-vertebral) disc has a tough fibrous outer layer and a more gel like inner layer. A normal disc works very well to cushion low back stresses without any problems at all by acting as a pressure resistant mobile ‘spacer’. Sometimes the outer wall of the back and sides of the disc can be strained, and this can cause pain (although not always). Occasionally, the gel like inner compartment can try to ‘push’ backwards through the outer layer (see illustration above). This is known as a herniating disc. A ‘slipped’ disc (more properly called a prolapsed disc) is when some gel material has actually escaped out of the back or sides of the disc. In this situation, it may (but not always) ‘trap’ a passing nerve root and cause sciatic pain in the leg (this problem is covered in the other guide).

Medication

There are two types of medication that can be used to manage pain in these situations. The first is regular pain killers that work by directly blocking the brain’s perception of pain, for example paracetamol. The second is anti-inflammatories, which work by reducing inflammation from the injured tissues, and thus indirectly reduce pain (as inflammation causes pain).

Pain killers and anti-inflammatories can be taken together to get a combined effect, but it is important that you don’t accidentally take two or more types of pain killer, or two or more types of anti-inflammatory, together. For example, some people take both aspirin and ibuprofen, not realising they are both similar anti-inflammatories. Check with your pharmacist or your doctor if in any doubt.

IMPORTANT:

It is essential that you have adequate pain relief. Don’t grin and bear it. Over the counter pain medications may not be strong enough, and you must see your doctor as soon as possible if you feel you need stronger medication.

A common side-effect from anti-inflammatories is a feeling of nausea or an upset tummy. If you get this, reduce your intake of anti-inflammatories, take them with food, and mention this to your doctor. Any previous history of gastric ulcers or bleeds, or of asthma, must be mentioned if you plan to take anti-inflammatories, even over the counter aspirin or ibuprofen (a common brand name of the latter is Nurofen).

There are four things that will allow the disc to heal properly and without undue delay. 

1. Time

Compared to muscles and joints of the low back, or even ligaments, the disc does not have a good blood supply. Whereas joint or muscle strains can settle within a couple of weeks if managed properly, a disc problem may take up to 10 weeks to settle, even if pain has subsided quite quickly. You must not be fooled by the absence of symptoms into thinking that an injured disc has finished its healing, or you may have a relapse at some point!

2. Avoiding sudden or sustained rises in intra-discal pressure (IDP)

Imagine you have a pressure meter probe inside the disc which reads from 0% to 100% (100% meaning danger!). The higher the pressure, the more strain on the injured areas at the back or sides of the disc. Lying on your back, the meter would read very low. Walking would also be quite low (good). Standing not so good. Leaning forward (e.g. assembling furniture, cleaning teeth, washing up, doing the car) is bad. Sitting (even proper sitting) is very bad. Sitting in a slumped position is almost disastrous. Of course, the longer you maintain a bad position, the longer the bad effects of high IDP have to work! This is why that even though one should minimise the time spent sitting, even if sitting properly, regular breaks from sitting every 10 minutes or so, even if only for a minute, will give time for the straining fibres to move back into position.

The key factor is – are your back muscles relaxed? Just remember that preventing your back muscles from working too hard or too long will keep IDP under control, and you will be half-way there. For example, sitting too far away from your desk and ‘reaching’ for the keyboard or mouse will trigger significant back muscle contraction, leading to peak rises in IDP.

3. Nutrition

Disc health may be helped by improving nutrition. Drink more water to hydrate the body. Consider taking 1000 mg of vitamin C a day, and a capsule of vitamin E, to assist in tissue healing, if only for a few months. Smoking is especially bad for disc health; consider cutting right down through any healing period.

4. Good movements

Movement is quite good for the healing disc as long as movements are gentle and do not produce sudden or sustained rises in IDP. If the disc is very painful and the injury is very new, then obviously rest rather than movement is very much indicated. But as pain subsides and time passes, the right way to speed up healing and promote good tissue formation over the injury site, is to progressively add good movement. Importantly, the fact that your low back might hurt through movement does not imply that any harm is being done; as long as pain is not sharp or severe, and as long as there is no increase in pain after movement has finished, some movement may well help as long as you don’t overdo it.

Surgery

If you have low back pain from a painful or weak disc, surgery is not really a viable option except for the most long standing and difficult cases as it has a poor track record (although surgery can be indicated for intractable sciatica of over 6-10 weeks duration). When all else has failed for low back pain, and a surgeon believes a disc is the cause of it, a steroid injection may well be considered, and in the future other more progressive techniques will likely be available. The surgeon will still want to be assured that a course of manual therapy has been tried, and proper rehabilitation (exercise strengthening) of the lumbar spine has been done, before considering any of these more invasive options.

Exercise

In the early stages, rhythmic movements of the low back while lying on your back will help. Later, walking and gentle swimming (less so breaststroke) are also very good.
Gym work may be useful during the intermediate stages of a healing disc.
However, rowing, cycling and treadmill are all inadvisable.
For cardio-vascular fitness, try cross-trainers or stair-masters instead. Road cycling may, however, be fine for the disc, especially mountain biking where the body is inclined forward and the body weight is borne through the arms.
Abdominal sit-ups should be done with care, until it is clear they do not aggravate the back during or after exercise.
At the appropriate time, resistance exercises for the arms and legs will indirectly help the low back, providing emphasis is placed on good posture and technique during the exercise.
Specific exercises to strengthen the muscles of the lumbar spine will also be important, and fall into a special category which needs discussing with your therapist or trainer.

Sitting

Sitting at the office or in the car has been discussed already. Slumping is VERY bad (see below), whereas sitting reclined (almost a lying down posture) is least bad.

Slumping is BAD!

Slumping is BAD!

Sitting more reclined - good if a disc problem!

Sitting more reclined - good if a disc problem!

Sitting with the low back relaxed against the back of the chair requires a good lumbar support, a relaxed upper back, and a quite reclined seat back to reduce the downward gravitational stress through the healing disc. If you want to sit in this way, your upper back MUST be relaxed against the back of the chair to avoid slumping.

If you must sit upright, then perch towards the edge of the chair (away from the seat back) and have your feet behind you so that your knees are pointing more down. Sway from the hips as you sit. Even so, keep this type of sitting to a minimum. 

Hard physical work

This is demanding on injured discs. If you simply have to work, then try a workwear support belt. Worn properly, this belt has the benefit of increasing intra-abdominal pressure, which causes the area in front of the spinal column to be more of a supporting column in its own right, thus reducing intra-discal pressure. My advice would be to use the belt only sparingly, when you really are using the back muscles a lot, and not while you are just walking around.