Lumbar Disk HerniationLast Updated; 1997.11.03
lumbar disk herniation is a very famous name of disease causing low back pain or sciatica. But very few people know the actual situation of this disease. The explanation below will help your understanding for lumbar disk herniation.
A. The structure of the intervertebral disk*Annular Ligament:
is a fibrous tissuue composing outer layer of intervertebral disk. This has many layers having its fibrous tissue crossing by X shape. this maltiple layers allow annular ligament for stronger structure and grater ability as a shock absorber .
is made of much glutinous liquid composing central part of intervertebral disk. This acts as a ball bearing and is balancing of the body.
B. Various Types of Disk Herniation
*Protoruded TypeNucleus pulposus is shifted posterior tearing annular ligaments partially. Then the disk protrude backward as a whole without extrusion of the nuleus pulposus from annular ligament. The nucleus pulposus is remaining just inside of the annular ligament in this case. When the protoruded disk suppress nerve root running through in that intervertebral foramina, severe sciatica will occur.
*Ruptured TypeNucleus Pulposus has gone out or extrude from the collapsed annular ligament. In almost all case, direction of the extrusion is posterior, and right or left. Also extruded nucleus pulposus will surppress the nerve root running near it in the intervertebral foramina, this will cause sciatica as above type.
*Fragmentation of the DiskAfter the middle age, when moisture decrease from the disk and calcification develope in the disk, the disk may lose its elasticity and may result in partial fragmentation. If a piece of fragmented disk drop into the intervertebral foramina, severe sciatica will occur.
*Schmorl's NoduleWhen the disk break through bone plate of upper or lower vertebral body, the nucleus pulposus may exude into the vertebral body. This is called Schmorl's Nodule. Usually this will not cause sciatica but may cause back pain.
C. The reason why the disk herniation can remedy by physical therapyProtrusion type herniation has the highest incidence among the all types of the lumbar disk herniation. In this type of herniation, if the nucleus pulposus can move back toward the normal anterior position from abnormal posterior position, protrusion of the whole disk will disappear and partially teared annular ligament will heal degenerating to the scar tissue. Accordingly various physical therapy - extension method used in orthopedics, spinal manipulation of chiropractic or acupuncture etc.- can be effective for this symptom.
We think that chiropractic will be most effective for protrusion type herniation among these physical therapies. Because, when fixed spinal facet(joint) is released by direct or indirect spinal adjustment, pump action will work to nucleus pulposus through normalized motion of the spinal segment, it is easy to move back to the normal anterior position. But rough manipulation would worsen the condition, so accurate adjustment must be done.
By the way, many patients with sciatica who have been diagnosed as disk herniation by orthopedics have not been examined by imaging method like MRI or X-ray CT, the cause of their symptom may be posterior displacement of lumbar spine narrowing the intervertebral foramina. Of course some patients would have both lumbar spine posteriority and disk herniation.
Meanwhile in the case of ruptured type and fragmented type, suppressed nerve
will not be released unless extruded disk or a fragmented piece of disk is
removed by surgical operation. But incidence of these type are lesser than
protruded type, then very few case should need surgery.
D. How to differectiate each type of herniationIn the chiropractic examinations, these herniation can be distinguished each other through certin reflexes or tenderness. Even imaging method such as MRI can not differenciate protruded type and ruptured type.
Orthopedics would use next treatments in steps. (1)First Step medicine *antiphlogistic & analgesic: will control pain and inflammation. *muscular relaxants: will release muscle spasm. *antiphlogistic enzyme: will take the swelling down. physical therapy *traction *heating method: infra-red, micro-wave, hot pack *low frequency electric therapy (2)Second Step: epidural anesthesia (3)Third Step: direct anesthesia for suppressed spinal nerve root (4)Last Step: surgery Surgical operation would be done under considaration about next points. *The patient has a leg numbness. *The patient has viscorectal disorder. *Leg pain is too severe to endure. *The patient has no time to spare due to his/her work or family reasons.Even if the surgery was done successfully, the adjacent disk seems has high incidence of herniation. A certaine orthopedist by whom the auther have been taught said that the probability of the recurrence of adjacent disk herniation will be 50% at 3`5 years later since operation. The orthopedist said also "A younger inexperienced doctor would like to do surgery, but an experienced doctor wouldn't like to do it because he knows high incidence of recurrent herniation." We should remember that this words owe a lot to many patients' expenditure and troubles of recurrent herniation.