Low back pain is one of the most heard complaints from many patients. Almost every adult now is complaining of low back pain. 

One of the most common causes of low back pain is slipped or herniated disc. 

So, what are these discs? 

You might think of the spinal column as a solid unit that is also flexible to allow movements in different directions. While, in fact, it consists of small moving parts that work together. Our spinal column is made up of a series of bones called the vertebrae, stacked onto each other. Each segment of our trunk has a specific number of vertebrae. The spinal column includes seven bones in the neck segment or cervical spine, 12 bones in the thoracic spine or the chest area, five in the lumbar spine, followed by the sacrum and coccyx at the base of the spinal column. 

The vertebrae are cushioned by flat round cartilaginous pads called the intervertebral discs. Both the discs and the vertebrae create a canal where the spinal cord runs inside it and the spinal nerves emerge from it. These electrical cables run inside the canal carrying messages from the brain to the muscles and other parts of the body. 

Intervertebral discs and the vertebrae protect the spinal cord and its nerves. These cartilaginous discs act as shock absorbers during walking or running. Each disc consists of two components: 

• A tough outer part called the “Annulus granulosa”.
• An inner softer jelly-like part called the “Nucleus pulposus”.

A herniated disc, also called bulged, ruptured, or slipped disc, happens when the pressure from the vertebrae above and below forces the nucleus out through a weakened or torn part of the annulus into the spinal canal.  The spinal canal is narrow with limited space. Therefore, the herniated disc can press on the spinal nerves causing pain and irritation which may be severe. 

Herniated discs can occur anywhere along the spine, but most frequently, they occur at the lower part of the spine. It is one of the most common causes of neck, leg, or back pain. Herniated discs occur more often in people aged 35 to 55. And they occur more in men than in women. 

But what are the symptoms of a Herniated Disc? 

Some people might have no symptoms at all and discover it by accident during a regular check-up or thorough investigation after a trauma or an accident. 

However, if patients experienced symptoms, it would depend on the site of the herniated disc. Here are some of the most common symptoms of herniated discs. Let’s start with symptoms of the lower back: 

• Leg pain. Pain mostly will be in the buttocks, thighs and legs. It may extend to include part of the foot as well. The pain might shoot into the leg when patients sneeze or cough or move into a certain position. The pain is often described as a shooting or burning pain. 
• Numbness or tingling. There will be numbness and tingling on the skin of the area supplied by the affected nerves. 
• Weakness. Muscles that are supplied by the affected nerves will be weak, patients might stumble or lose the ability to lift or hold items. 

Symptoms of a herniated disc in the neck include: 

• Pain near or over the shoulders. 
• Pain that radiates to the arm, shoulders and sometimes hands and fingers. 
• Neck pain especially on the back and the sides of the neck and it might increase during certain movements. 
• Spasms of the neck muscles. 

As for symptoms of herniated discs in the mid-back, symptoms tend to be vague. There might be a dull pain in the upper back or the abdomen. 

But how would a disc be herniated? Why does this happen? 

As we age, our discs become more liable to tears or rupture even with a minor twist or strain. This is mainly because discs become less flexible as we age. There is a gradual ageing-related process called “disc degeneration” with continuous wear and tear of the discs. 

Sometimes using back muscles instead of leg muscles during lifting heavy objects can lead to disc herniation, or twisting while lifting a heavy object. It is rarely caused by a traumatic event like a fall or a blow to the back. 

However, some risk factors can increase the risk of disc herniation, including:

• Excess weight. Overweight causes extra stress on the discs on the lower back. 
• Smoking. Some experts think that smoking decreases the oxygen supply of the discs, which makes it more liable to tears. 
• Occupation. People who have jobs that demand strenuous physical effort are more liable to get their discs herniated. Jobs that require repetitive lifting, pulling, bending sideways and twisting can significantly increase the risk of disc herniation. 
• Genetics. 

The herniated disc cannot occupy the whole spinal canal. The spinal cord itself ends just above the waist and the rest of the canal is occupied by a group of spinal nerves that look like a horse’s tail and called “Cauda Equina”. 

Continuous pressure on these nerves can cause permanent weakness, paralysis, and other serious complications including:

• Chronic back or leg pain. 
• Loss of control or sensation on the legs or feet. 
• Bladder or bowel dysfunction. It may escalate to incontinence or difficulty urinating even with a full bladder. 
• Saddle anesthesia. Progressive loss of sensation can affect the inner thighs, the area around the rectum, and the back of the legs. 

These complications can be easily prevented by some simple measures and lifestyle changes, such as: 

• Exercising to strengthen the trunk muscles and support the spine. 
• Quitting smoking to improve the oxygen supply of the discs. 
• Maintaining a good posture to reduce the pressure on your spine and discs. Keep your back aligned and straight when you are sitting for long periods at work or during driving. Lift heavy objects cautiously and properly, try to use your leg muscles instead of your back muscles. 
• Maintaining a healthy weight to reduce the pressure on your spine and discs. 

So, how is a herniated disc diagnosed? 

Your doctor will evaluate your case through several steps. First, your doctor will begin with taking a detailed history from you. He\she will concentrate on any previous traumas, blows to the area of pain, sudden strains or twists. He\she will ask you about your occupation as well. 

After that, a complete physical examination will be conducted. He\she might also perform neurological examinations to test your muscle strength, sensations, walking ability and muscle reflexes. Your doctor will check your back for tenderness and ask you to lie flat and move your leg in various positions to determine the origin of the pain. 

In most cases, history and physical examination are all that’s needed to diagnose a herniated disc. However, if your doctor suspects a certain condition or needs to know which nerves are affected, he\she might ask for some investigations such as:

• X-rays. 

X-rays cannot detect a herniated disc, however, they can rule out other causes of back or neck pain such as infection, tumors, or broken bones. 

• CT scan

It gives the doctor an idea about the spinal column and the structures around it. 

• MRI

Magnetic resonance imaging is used to view the body’s internal structures clearly.  It can confirm the presence and the location of the herniated disc and locate the affected nerves.

• Myelogram. 

A dye is injected into the spinal fluid then it is filmed by X-rays. It can show any site of pressure on the spinal cord or nerves due to herniated discs or any other conditions.

• Electro myelogram (EMG)

It involves placing small needles into specific muscles to measure their electrical activity. The muscle response represents the degree of nerve activity. It can help your doctor to determine which nerve root is affected by the disc herniation. 

• Nerve conduction study. 

It measures electrical nerve impulses and the functioning of the nerves. It measures even the slightest nerve impulses when signals or electrical currents pass through your nerves. 

What is the treatment of disc Herniation? 

As for the treatment of disc herniation, it is mostly conservative treatment. Most herniated discs resolve on their own with this conservative treatment. Lifestyle and activity modifications are mainly done to avoid movements that induce pain. Pain medication can also be taken to do daily life activities comfortably, they can relieve the pain in a few days or weeks in most patients. Some of the common over the counter painkillers are aspirin, ibuprofen, and naproxen.

Some people find that ice packs and application of heat to the affected area provides relief of the pain and resolve the spasms of the muscle of the back. 

In resistant cases, when symptoms don’t improve with conservative treatment, spinal injections and even surgical options are considered. 

Our role today is to answer most of your questions regarding Intervertebral Hernia. Today we have Doctor Kim who is a leading doctor at Jaseng Hospital of Korean Medicine in Seoul. He is going to discuss with us everything about Intervertebral Hernia from an experienced medical point of view.

Interview

Intervertebral hernia - what is it?

Commonly referred to as a disc, this disc is not a disease name, but a spinal anatomy. There is a substance between the bones of the spine that can relieve the impact of the bones – this substance is called a disc.And the case where the discs are gradually pushed out by impact is called a disc herniation.

What are the symptoms for a slipped disc?

This is the disc you see here. The disc that pops out by pressure is called a slipped disc, and there is a nerve behind this disc. When these discs press on the nerves, it hurts the back, hips and legs, which are the pathways through with the nerves pass. Because it’s a nerve problem, numbness in the leg, aching, or pulling pains are typical symptoms of a slipped disc.

What are the different types of hernia?

Discs can be roughly divided into four types. At first, the pressure starts, also called bulging, so the first stage is where the disc is swollen. The second is called protrusion, and the protruding disc is called a second-stage disc. When the pressure becomes more intense, it is called extrusion, and the state where the disc has penetrated through the ligaments is expressed in the third stage. The fourth is when the popped discs flow downward, and this is called sequestration. So the disc is classified into a total of four types.

How do you diagnose if it’s a herniated disc or not?

Firstly, when doctors see patients, they do a test. They put the patient on their stomach and try to raise their leg or see how much strength they have in his ankles. And see if there is a difference in sensation, and to determine if this is a nerve problem or a muscle problem. To be more accurate, we can actually take X-rays, CT and MRI, but MRI is the most accurate way to diagnose and evaluate the stage of a herniated disc.

In the case of a patient with a herniated disc, what are the treatments available?

In the case of disc patients, as we’re in Korea, there are things that can be treated with both western medicine and Korean medicine. With western medicine, things that can be easily used are painkillers, injection therapy, or physical therapy and exercise therapy.

In Korean medicine, there is something called chuna therapy. Acupuncture, herbal acupuncture and herbal therapy are also used to approach disc treatment.

Who is more at risk of a herniated disc?

Back in the day, people who actively used their spine and the elderly were at risk of spinal diseases, but these days it is not. Nowadays, anyone in their 20s to 60s can have spinal pain. Because modern people sit for a long time and use computers, their postures are damaged, and muscles are weakened. So anyone can easily develop spinal diseases.

How do you differentiate between diseases of the spine and other diseases?

It’s a difficult question, but since it’s a spinal problem, of course it may be that it hurts when the spine moves or when the joints move. And conversely, it may be caused by tension in these muscles around the spine rather than the spine itself, or the same symptoms may also occur due to problems with blood vessels. Therefore, it can be said that this requires tests that doctors can diagnose by themselves.

How effective is the Korean medicine in treating hernia?

Of course, as I’m a Korean medicine doctor, I would recommend Korean medicine. But for disc treatment, because discs can be treated without surgery, Korean medicine opposes surgery. The advantage of Korean medicine is that it does not focus on the disc that’s simply causing the pain, but rather the treatment that changes the environment and structure in which the disc is occurring.

For example, there are people who have a disc pain due to a twisted pelvis. For these people, we use chuna therapy, which corrects the distortion of the spine by correcting the legs and pelvis. Then, spasticity, stiffness and tension in the muscles that may be caused by these discs or inflammations are released through acupuncture and herbal acupuncture. More importantly, there is a herbal medicine made with natural drugs that can heal the disc for inflammation and wounds on the protruding area.

When this herbal medicine enters, the wounds on the disc are reduced one by one, and the disc phenomenon gradually subsides, and the spine can be strengthened in a healthier shape than before. That’s why I’m saying that Korean medicine treatment is a fundamental treatment and a good way to strengthen it.

You said that anybody can suffer from this disease, how do average people prevent this disease?

There are two things I’m emphasizing. One is posture and the other is exercise – yes. Those who come to the hospital, strangely, all have bad posture. It’s because it hurts because the posture is bad. When they come, they all sit like this. The back is curved, and the neck is out. This is how they live. They walk like this as well. Because of this, it hurts the neck and lower back more and more. The first thing is to make your posture right. Modern people usually sit because they don’t have time to walk, so their muscles weaken. It’s all because of these foctors, so if you do them well, you can protect and  strengthen your spine much more.

What kind of sports do you advise people to do? Is it like weight training or sports that help the strength of the body?

These days, the trend is yoga, pilates, and everyone does PT a lot. It is really good exercise. But patients with spinal problems shouldn’t start this kind of exercise right away. Spinal patients already have tight muscles, so they need to release these muscles before strengthening them. But the best thing to relax your muscles is walking. However, people don’t walk often and don’t walk in the correct posture. In just 30 minutes of walking correctly with your chin pulled in, you can keep your spine strong and well maintained.

If someone had a sudden herniated disc, what kind of first aid can we provide to them?

In case of acute pain, of course it is good to go to the hospital, but if it is too painful to move, the first thing is to rest until the pain subsides. So, lying down in the most comfortable and less painful position in bed. The important thing is that if you put an ice pack on the sore area, the inflammation and pain subsides in about 2-3 days. Then, it is better to visit the hospital afterwards for diagnosis and treatment.

You’ve told us before about Korean medicine as a solution for herniated discs. Are there any surgical interventions that are done in the case of herniated discs?

In our experience, when we look at spinal patients, about 1 in 10 people need surgery. It’s not that all patients can’t have surgery but there are always patients that need it. The test may consider surgical methods if the patient’s muscle strength, leg and arm strength is too low, they can’t sleep at night, or the pain is out of control. So, 1 in 10 people need surgery and you can see the symptoms that require surgery.

The most important thing is that there are symptoms of failed muscle strength in the legs, weakness in the arms and legs.

Secondly, if you have been treated for 3 months but you can’t stand the pain, in that case you can do surgery. The most important thing is cauda equina syndrome, which is a dangerous symptom.

What this means is that if the disc is too big and puts hard pressure on the nerves, it can cause problems with stool and urine. Some people say they do not know when the sphincter is loosened and the stool leaks without them knowing. Or they want to urinate but it doesn’t come out. These people are those who need emergency surgery quickly. But if that’s not the case, then it’s not a good idea to have surgery just from symptoms such as pain.

Conclusion

Intervertebral hernias are commonly referred to as herniated discs. This is when the intervertebral disc slides outward and presses on one of the spinal nerves. It can be classified into four stages depending on the degree of disc slip. The symptomatology of this hernia is dominated by pain along the path of the affected nerve. The diagnosis is clinical but can be supplemented by X-rays, T-CT and MRI for a more precise analysis. The treatment remains as conservative as possible except for a few specific cases.