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Lumbar Disc Bulge

(Also known as Bulging Disc, Disc Prolapse, Slipped Disc, Prolapsed Disc, Herniated Disc, Intervertebral Disc Injury, Sprained Disc)
What is a lumbar disc bulge?
The lumbar spine (i.e. lower back) comprises of many bones known as vertebrae, each of which is separated by a disc. The disc comprises of many layers of strong connective tissue wrapping around the disc. In the middle of the disc lies a soft jelly-like substance which is capable of changing shape. When this jelly-like substance protrudes from the disc due to a tear in several layers of the connective tissue, this is known as a lumbar disc bulge.
To understand the mechanism of a lumbar disc bulge, it is useful to liken the disc to a vanilla slice. Imagine a vanilla slice wrapped in five layers of sandwich wrap. The top and bottom layers of pastry represent the vertebra (bones), the custard represents the jelly-like substance of the disc and the sandwich wrap represents the connective tissue around the disc. If you were now to pinch the front of that vanilla slice, you could imagine, the custard would squeeze towards the back of the vanilla slice and may tear two or three layers of sandwich wrap at the back of the vanilla slice. As a result the custard is no longer supported as effectively at the back of the vanilla slice and therefore bulges out at this location. In the disc, the situation is the same. Bending forward closes down the front of the disc, pushing the jelly-like substance within the disc towards the back. Overtime or suddenly, this may tear several layers of connective tissue at the back of the disc resulting in a disc bulge.
Lumbar disc bulges most commonly occur in those who are 20 to 50 years of age. The lowest disc of the spine (L5/S1) is most commonly affected with the disc above (L4/L5) the second most common.

Causes of a lumbar disc bulge

There are three main activities in everyday life which typically cause lumbar disc bulges provided they are forceful, repetitive or prolonged enough. These include: bending forward, sitting down and lifting (especially in combination with twisting). Occasionally, lumbar disc bulges may occur following a trivial movement involving bending forward such as picking up a small object or sneezing. In these instances, the disc has normally been subject to repetitive or prolonged bending, sitting or lifting forces leading up to the incident.

Signs and symptoms of a lumbar disc bulge
Patients with this condition may experience a sudden onset of back pain during the causative activity, however, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning. Symptoms are typically felt in the lower back and may be located centrally, on one side or on both sides of the spine. The patient may experience pain radiating down the leg into the buttocks, thigh, lower leg or foot (sciatica). Muscle spasm, pins and needles, numbness or weakness may also be present. In some cases, patients may appear to stand with their spine noticeably out of alignment as a result of the disc bulge. Symptoms are generally exacerbated with activities involving lifting, bending forwards, prolonged sitting, or when moving from sitting to standing (e.g. getting out of the car). Coughing, sneezing and twisting may also aggravate symptoms. Patients with a lumbar disc bulge often experience pain that is worse first thing in the morning.

Diagnosis of a lumbar disc bulge

A thorough subjective and objective examination from a physician is usually sufficient to diagnose a lumbar disc bulge. Investigations such as an MRI or CT scan may be required to confirm diagnosis.

Conservative treatment — mainly avoiding painful positions and following a planned exercise and pain-medication regimen — relieves symptoms in nine out of 10 people with a herniated disk. Many people get better in a month or two with conservative treatment. Imaging studies show that the protruding or displaced portion of the disk shrinks over time, corresponding to the improvement in symptoms.

  • Over-the-counter pain medications. If your pain is mild to moderate, your doctor may tell you to take an over-the-counter pain medication, such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others). Many of these drugs carry a risk of gastrointestinal bleeding, and large doses of acetaminophen may damage the liver.
  • Narcotics. If your pain doesn't improve with over-the-counter medications, your doctor may prescribe narcotics, such as codeine or a hydrocodone-acetaminophen combination (Vicodin, Lortab, others), for a short time. Sedation, nausea, confusion and constipation are possible side effects from these drugs. Decrease or eliminate your Tylenol use if these combination medications are prescribed.
  • Nerve pain medications. Drugs such as gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), tramadol (Ultram, Ryzolt) and amitriptyline often help relieve nerve-damage pain. Because these drugs have a milder set of side effects than do narcotic medications, they're increasingly being used as first-line prescription medications for people who have herniated disks.
  • Muscle relaxers. Muscle relaxants such as diazepam (Valium) or cyclobenzaprine (Flexeril, Amrix) also may be prescribed if you have back or limb spasms. Sedation and dizziness are common side effects of these medications.
  • Cortisone injections. Inflammation-suppressing corticosteroids may be given by injection directly into the area around the spinal nerves, using spinal imaging to more safely guide the needle.

Physical therapists can show you positions and exercises designed to minimize the pain of a herniated disk. As the pain improves, physical therapy can advance you to a rehabilitation program of core strength and stability to maximize your back health and help protect against future injury.

A physical therapist may also recommend:

  • Heat or ice
  • Traction
  • Ultrasound
  • Electrical stimulation
  • Short-term bracing for the neck or lower back

A very small number of people with herniated disks eventually need surgery. Your doctor may suggest surgery if:

Conservative treatment fails to improve your symptoms after six weeks
  • A disk fragment lodges in your spinal canal, pressing on a nerve and resulting in progressive weakness
  • You're having significant trouble performing basic activities such as standing or walking
  • In many cases, surgeons can remove just the protruding portion of the disk. Rarely, however, the entire disk must be removed. In these cases, the vertebrae may need to be fused together with metal hardware to provide spinal stability. Or your surgeon may suggest the implantation of an artificial disk.

Prognosis of a lumbar disc bulge
In patients with the perfect balance of activities, the lumbar disc may be pushed into position in as little as three days. Typically, however, patients take approximately 2 to 3 weeks to push their disc back 'in'. Once the disc is 'in', the patient should be pain free and have full movement. However, the torn connective tissue at the back of the disc only begins to heal from this point. It takes approximately six weeks of consistently keeping the disc 'in' to allow the torn tissue to heal to approximately 80% of its original strength.

Contributing factors to the development of a lumbar disc bulge
Several factors may contribute to the development of a lumbar disc bulge. These need to be assessed and corrected with direction from the treating physical therapist and may include:
  • poor core stability
  • a sedentary lifestyle
  • being overweight
  • muscle tightness
  • muscle weakness
  • joint stiffness
  • poor lifting technique
  • poor posture
  • a lifestyle involving large amounts of sitting, bending or lifting

Physical therapy for a lumbar disc bulge
Physical therapy treatment for a lumbar disc bulge is vital to ensure an optimal outcome and may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • lumbar taping
  • bracing
  • mobilization
  • traction
  • the use of a lumbar roll for sitting
  • ry needling
  • exercises to push the disc back 'in' and to improve strength, core stability and flexibility
  • education
  • activity modification advice
  • biomechanical correction
  • ergonomic advice
  • clinical Pilates
  • hydrotherapy
  • a functional restoration program
  • a gradual return to activity program

Other intervention for a lumbar disc bulge

Despite appropriate physical therapy management, a small percentage of lumbar disc bulges fail to improve and may require other intervention. This may include further investigations such as an X-ray, CT scan or MRI, pharmaceutical intervention, assessment from a specialist or sometimes surgery. Your physical therapist will let you know if this is required and will refer you to the appropriate medical authority if it is warranted clinically. In cases of persisting or worsening neurological symptoms (pins and needles, numbness and weakness), surgery may be indicated. When a loss of bowel or bladder control is present due to the disc bulge, this is considered a medical emergency and immediate surgical intervention is usually required.