Lumbar Disc Injury Document 

A lumbar (lower back) disc injury typically  involves disruption, injury or degeneration of  the intervertebral disc in the lower end of  the spine (commonly to the L4/L5 or L5/S1).  It may range from an array of types of  injuries to the disc. These are disc  degeneration, disc bulge, disc protrusion,  disc extrusion, or disc sequestration,  potentially causing nerve root compressionThe Lumbar spine consists of five vertebrae (Spinal bones) named L1,L2, L3, L4, L5.  These spinal bones primarily protect the spinal cord and support the body to allow for  mobility. The main movement enabled by a lumbar spine is flexion and extension  (bending forwards and backwards), with mobility also allowing for some side to side  and rotation movements. The Discs act as shock absorbers between each vertebrae  and allow movements between each vertebrae.  The anatomy of the lumbar disc consists of an inner gel-like substance core called the  nucleus pulposus. This is surrounded by a tougher external layer called the annulus  fibrosus. There are also ligaments that surround the discs along the spinal column that  create more stabilisation to these structures. When movements are completed such as  forward flexion, the disc becomes squished and it is forced to translate backwards.  So what may happen to the disc in the case of a lumbar disc injury? Commonly when a lumbar disc is injured it is due to either an accumulation of load or  stress or an acute disproportionate stress placed on the structure, causing there to be  injury to the disc either by irritation of the annulus fibrosus or specific pathology  sustained. This can be from activities such as lifting or bending-based manoeuvres.  Often forward bending, lifting or prolonged sitting can be difficult and painful, whereas standing and walking can be relieving.  Pathology in more severe presentations may be from the nucleus pulposus being  forced to break through the outer annulus fibrosis layers (herniation). This term is an  umbrella term that can further be sub-categorised depending on how far it has been  pushed out.  Regardless of its herniation factor, all these types of injuries may irritate nearby  structures including the spinal nerves, resulting in the potential to have referred lower  limb pain, sensation deficits and even strength alterations. Imaging: Lumb disc injuries can undergo many different types of imaging to help with  diagnosis. When investigating a lumbar disc injury, different types of imaging may be  used depending on your symptoms and clinical findings, there is no one specific gold standard. MRI (Magnetic Resonance Imaging) is the most common and effective scan  for detecting disc bulges, herniations, and nerve involvement. It provides detailed  images of soft tissues without using radiation. CT scans are useful for assessing bones  and may be recommended if an MRI is not suitable, particularly in relation to cost,  though they do provide less detail of soft tissue. X-rays are often used as a first-line  scan to rule out fractures or spinal alignment issues, but they cannot show disc or  nerve problems. In some cases, a CT myelogram, a more specialised scan involving  contrast dye, may be used when additional detail is needed or if an MRI cannot be  performed. Most disc injuries improve with conservative care, and imaging is only  recommended when necessary to support diagnosis or guide treatment. Lumbar disc injury types: 1) Disc degeneration: Disc degeneration refers to the degeneration and  breakdown of the discs in the spine. As we  lose the liquid content/hydration of the  disc they begin to become shorter and  more prone to not absorbing load well,  dis-enabling quality movements and  narrowing the spinal canal. This can be  associated with pain and stiffness.  Although this is a natural part of aging, it  can also be catalysed by injury and  repetitive stress.2) Disc bulge: A disc bulge occurs when the  disc’s outer layer (annulus fibrosus) is  weakened or stressed and the inner gel like substance (nucleus pulposus) bulges  outwards. It has the potential to irritate  structures such as the nerves and cause  pain, sensation alterations (numbness,  tingling etc), and referral into the lower  limb. It is not as serious as the following  types explained.3) Disc Herniation: A disc herniation can be  categorised more specifically as either an  extrusion or sequestration. An extrusion is when the nucleus pulposus breaks through the annulus fibrosis but it remains connected to the main disc, while  sequestration is when a portion of the nucleus breaks off completely and moves  away from the main disc. Sequestration is considered a further stage to disc  herniation compared to disc extrusion. The displaced fragment can cause  significant pain and neurological symptoms by irritating or compressing nerves.  What does the evidence show for disc injuries correlated to imaging for  asymptomatic individuals vs symptomatic individuals ?  It is essential to keep in mind that many research  literature has shown that when imaging is  completed there is a high number of  asymptomatic individuals who in their results  illustrate having pathology. These are people  who are functional or don’t have present pain.  Some of the statistics around this demonstrate 37% of 20 year olds have disc degeneration  and 50% at 30 years old. These people are all  symptomatic. It also illustrates that 30% of 20  year olds and 40% of 30 year olds have disc bulges. The take home message here is that  a large portion of people who have these seemingly severe pathologies are functioning well and have no pain, highlighting the importance of utilising these results in  conjunction with clinical assessments. This is why it is important to see your  physiotherapist and not be completely misguided or demoralised by imaging alone.  Treatment/Management:  Everyone will be diXerent due to the type and severity of the injury. Some of the  following are methods of treatment and management for lumbar disc injuries. These  will all be individualised and provided appropriately based on the clinical presentations  assessed by your physiotherapist.  1) De-loading and rest: Initially it is important that we respect the body’s pain and  healing time parameters. Therefore, having a period of rest and de-loading is  essential to begin recovery. This does not mean to strictly sit on the couch and  do nothing, it is more related to avoiding and minimising aggravating movements  such as bending, lifting and sitting for sustained periods.  2) Manual therapy: Your physiotherapist may use diXerent hand-on techniques  such as soft tissue work and mobilisations to improve your pain and mobility.  Other techniques such as dry needling and cupping may be utilised on a case by-case basis. Taping may also be applied acutely to help support your lower  back into a better posture to encourage de-loading and restricting painful  motions to help with pain and healing.  3) Medical/Referral: Your physiotherapist may provide education regarding the use  of over-the-counter lower dose anti-inflammatory medications such as  ibuprofen, and pain killers like paracetamol. This is encouraged to be discussed  with your medical professional. In addition, if stronger anti-inflammatories or the use of muscle relaxant medications are indicated, this will be prescribed in  conjunction with your medical professional’s opinion.  Unfortunately, in some more severe scenarios it may be necessary to be referred  for certain imaging (as explained earlier) or even a specialist review for their  opinion on management.  4) Early gentle movements: Early movement via pain-free tolerated gentle  exercises can be vital in reintroducing and desensitising normal movement  behaviour patterns, as well as improving or minimising further decline in  mobility.  5) Education: Advice surrounding correct postures, biomechanics and lifting  techniques will be shared to enable you with the best tools, knowledge and  pacing strategies to improve and sustain your long-term health.  6) Exercise-rehab: Your physiotherapist will formulate and integrate an  individualised tolerable progressive rehab program (including core, back and  lower limb strength/mobility). This will aid to improve pain, mobility and strength  so that you can return in a graded manner to your work, daily tasks and leisure  activities.