Disc Herniation / Derangement

Written by Dr. Jason Ngan, DC

What is Disc Herniation / Disc Derangement?

Disc derangement (aka discogenic pain) is a general term for an intervertebral disc (IVD aka disc) dysfunction. IVDs are joints between two vertebrae of the spinal column. They allow the spine to move, transmit forces, and absorb shock from compressive loads. The IVD contains an inner part made of a gel-like substances called the nucleus pulposus (NP). The NP is surrounded by multiple layers of fibrocartilaginous tissue called the annulus fibrosus. In disc derangement, the nucleus pulposus breaks through the annulus fibrosus and irritates spinal nerves. When enough nucleus pulposus breaks through, it causes a disc to bulge. There are four classifications of disc bulges:

  • Disc herniation (aka slipped disc, ruptured disc, disc bulge) is a general term for IVD pushing out. The annulus fibrosus is ruptured and the nucleus pulposus breaks through. The outer portion of the annulus fibrosus is still intact and its shape is mildly displaced.

  • Disc protrusion occurs when more nucleus pulposus infiltrates into the annulus fibrosus causing a focal outpouching of the annulus fibrousus. The outer portion of the annulus fibrosus is still intact but its shape changes and can press onto a nerve.

  • Disc extrusion occurs when the nucleus pulposus completely split up the annulus fibrosus. All the layers of the annulus fibrosus are disrupted and allows the nucleus pulposus to leak out. However, the nucleus pulposus is still attached to the annulus fibrousus.

  • Disc sequestration (aka disc prolapse) occurs when the nucleus pulposus breaks through and leaks out of the annulus fibrosus. The nucleus pulposus is not attached to the annulus fibrosus anymore.

What Causes Disc Herniation / Derangement?

Disc derangement are most common in the lumbar spine (low back) since it experiences the most compressive forces in the spine.

  • Disc degeneration is usually caused by age-related wear-and-tear (osteoarthritis) of the IVD

  • Lifting heavy objects puts too much stress on the IVD’s

  • Overweight/obesity also adds a great amount of stress to the IVD’s

  • Repetitive bending or twisting the back can wear out the IVD over time

  • Prolonged sitting or standing puts stress on IVDs as well

What are the Signs and Symptoms?

  • Pain from the spinal nerve being compressed.

    • Pain quality can be sharp, numb, or tingling.

  • Radicular pain: pain that travels down the arms (cervical disc herniation) or legs (lumbar disc herniation). When pain goes down the leg from a disc herniation, it is called sciatica secondary to disc herniation.

  • Muscle weakness in the arms (cervical disc herniation) or legs (lumbar disc herniation).

  • Pain is worse with bending forward since the disc bulge will put more pressure onto the nerve in this position.

  • Pain is worse with coughing, sneezing, and bearing down to use the restroom.

How is Disc Herniation / Derangement Diagnosed?

Early stages of disc derangements are hard to visualized on imaging. A thorough medical history, physical exam, orthopedic testing, end-range loading assessment can suggest disc derangements. Discogram, MRI, and CT scans are able to visualize disc herniations. X-rays is a useful tool to rule out other pathologies and it can show indirect findings of herniation such as decreased disc height, and degenerative changes.

What are the Treatment Options?

Some options we provide are:

  • Chiropractic manipulation and mobilization

  • Flexion-distraction

  • Spinal traction

  • Soft tissue release to treat the surrounding muscles

  • E-stim and ultrasound to decrease pain

  • Ergonomic/postural counseling

  • End-range loading exercises to decrease the pain going down to the legs and arms. These exercises aim to put less stress on the effected nerve.

Other treatments that patients may seek (not provided at Ngan Chiropractic) include acupuncture, epidural steroid injections, and surgery if severe.  

References

  1. Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med. 2017 Dec;10(4):507-516. doi: 10.1007/s12178-017-9441-4. PMID: 28980275; PMCID: PMC5685963.

  2. Crockett, K.L., Bourassa, R. & Friesen, T. Anterior disc derangement with reduction of the temporomandibular joint: a case report. J Med Case Reports 12, 148 (2018). https://doi.org/10.1186/s13256-018-1637-8

  3. Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc Herniation. [Updated 2022 Jan 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441822/

  4. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014;14:180–91.

  5. Mann SJ, Lam JC, Singh P. McKenzie Back Exercises. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539720/

  6. Shokri, E., Kamali, F., Sinaei, E. et al. Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study. Chiropr Man Therap 26, 16 (2018). https://doi.org/10.1186/s12998-018-0185-z

  7. Yu, P., Mao, F., Chen, J. et al. Characteristics and mechanisms of resorption in lumbar disc herniation. Arthritis Res Ther 24, 205 (2022). https://doi.org/10.1186/s13075-022-02894-8