The Disc Basics, The Back Exposed.
We begin today by knowing if you wanna specialize in Disc injuries, you need to be well acquainted with the anatomy. This will assist you in reviewing MRIs, and doing your exam, and making your diagnosis. Early on prior to decompression, the patient was often referred to the hospital where traction was administered.
Anatomy
Discs are soft, rubbery pads found between the hard bones (vertebrae) that make up the spinal column. Think of a marshmallow cookie, the soft marshmallow inside represents the disc. The spinal canal is a hollow space in the middle of the spinal column that contains the spinal cord and other nerve roots. The discs between the vertebrae allow the back to flex or bend. Discs main function is to act as shock absorbers.
Discs in the lumbar spine (low back) are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). The lumbar spine usually represents the largest discs, in the cervical spine (neck), the disks are similar but smaller in size.
Pathophysiology
For centuries doctors have tried treating disc problems. Prior to Dr. Dyer’s original approach toward non-surgical spinal decompression, there was no standard treatment. In the early part of the 19th century, intervertebral disc protrusion and subsequent pressure on the sciatic nerve roots were thought to be the likely source of sciatica and were hard to diagnose. When I was first in practice the diagnostic test of choice was a mylogram, which usually was negative. Prior to my graduation from chiropractic school in 1978, MRI’s were not yet available. Early in my carer, I invested in an MR! center with Dr. Bruce Rodan a Duke trained radiologist, who trained me on the reading and importance of this diagnostic tool.
Early on prior to decompression, the patient was often referred to the hospital where traction was administered. I remember visiting a family member and the apparatus was quite archaic. Simply said they would hang weights from the patient's legs and the nurse or doctor would continually add more weight. Until Drs Dyer and Shealy came along.
Early studies showed Disc traction, was ineffective and surgery became the popular way of treatment in the medical world. The medical community believed surgical removal of the disc would relieve the pressure on the nerve. By the mid 19th century many publications presented arguments that pressure on nerves leads to loss of function and rarely to pain. Multiple studies have shown that patients are frequently asymptomatic despite having significant disc pathology. Pain is only one indicator of DDD, often pain only surfaces at a late stage in the pathology. Early detection creates better results with any form of treatment. Remember, patients that have symptomatic disc herniation may not experience relief from removal of disc material or other causes of compression, while others experience significant relief in the absence of any intervention. Although the pathophysiology is still not clearly understood, there is evidence to suggest that the nucleus pulposus triggers an inflammatory response in sciatic nerve roots and may lead to pain. Contrary to previous theories, multiple factors including inflammation, abnormal immune factors, and mechanical compression of the nerve are likely involved in producing pain.
Causes of Back Pain
Each vertebra is separated by an intervertebral disc, which is a soft cushion that provides support and absorbs the stress that the vertebrae receive during daily activities. The disc consists of an inner, gel-like substance called the nucleus pulposus, and an outer fibrous membrane called the annulus fibrosus. A herniated intervertebral disc, results from the weakening and bulging outwards of the annulus, and protrusion of the nucleus, which most commonly occurs posterior or backwards. The spinal disc is in close vicinity to the nerve roots as they branch from the spinal cord and exit between the vertebrae. Therefore, a disc protrusion in the lumbar spine may compress one or more nerve roots causing pain to radiate into the back or legs. As mentioned above, the nucleus pulposus may cause inflammation of surrounding tissue which may cause further compression of the nerve root.
Common Causes of Pain
Sciatica
There was not a day in practice that someone did not come to my office with pain that exemplified sciatica. Sciatica is a common diagnosis utilized in the back business, yet it is a term not always fully understood. One of the first indicators of lumbar disc involvement is sciatica. It is important the doctor does a thorough workup, to fully document the pain and positive exam finding associated with this condition. Sciatica is a condition of pain that is found along the distribution of the sciatic nerve and is secondary to the pathology of the nerve itself. The sciatic nerve is derived from the lumbar and sacral spinal nerves L3 to S3 and receives fibers from both the anterior and posterior divisions of the lumbosacral plexus. Sciatica is a common diagnosis, the sciatic nerve runs through the buttocks, down the back of the leg, behind the knee, and branches before reaching the foot. The sciatic nerve controls the muscles of the back of the knee and lower leg and provides sensation to the back of the thigh, part of the lower leg, and the sole of the foot. As a student at New York Chiropractic College, we were taught the importance of the sciatic nerve and that the sciatic nerve is the largest nerve in the human body, nearly the same diameter as a finger. The pain associated with sciatica is usually an indicator of a bulging disc. Sciatic pain is usually felt as pain radiating from the buttocks down the back of the thigh into the calf and foot. Sciatic pain is usually very severe, many patients report, sharp, shooting, burning, or shock-like, pain, typically present along the nerve, but may present as “hot spots” of worsened pain along the length of the nerve. Even simplistic activities like sitting, standing up, walking, coughing, sneezing, or other sudden movements may worsen the pain. The term “sciatica” is commonly overused for any and all referring pain associated with the back.
"Multiple studies have shown that patients are frequently asymptomatic despite having significant disc pathology."
We must remember, there are other structures in the spine and pelvis that may also be responsible for referred pain to the buttock and leg, such as the sacroiliac joints, facet joints, and intervertebral discs. Associated numbness and/or tingling indicates a neuropathic source of pain like sciatica and helps to differentiate it from “other” causes. It is for this reason diagnostic imaging studies are so important prior to rendering your final diagnosis.
I have found with chiropractic care, there are many techniques that may help or eliminate the pain associated with sciatic. Cox, SOT, Thompson, Pierce Stillwagen, Logan, to name a few. Many patients with sciatica respond to conservative treatment and the symptoms tend to resolve in a matter of weeks to months. Even though the majority of sciatica pain is self-limiting, when present in the following situations a person should seek medical attention. Often severe sciatica may be associated with a bulging or herniated disc.
Bulging Disc
To really understand what a bulging disc is, I will discuss the classifications to describe the disc lesions. Diagnoses commonly encountered are disc prolapse and bulging disc (once called slipped disc, ruptured disc, and disc herniation). Decompression NSSD decompression therapy and treatment will vary based on the level of disc pathology. The treating doctor must understand that no single treatment protocol is right for all patients. Each doctor must utilize the protocols recommended by the manufacturer for his/her specific problem. What I have learned is many companies do not offer treatment protocols; this makes it difficult for the doctor to create a treatment protocol. Look for a machine that offers specific treatment plans based on documented research. In a world where everyone claims to be the expert, the true expert is in the documented, research. When looking to invest in any machine, look for a machine with documented research, proper FDA credential, and protocols that will assist you in treatment.
Herniated Disc
The intervertebral discs are found between each vertebra in the human spine. Like the vertebrae, there are seven cervical (neck), twelve thoracic (mid-back), and five lumbar (lower back) discs. The discs make up approximately one-third of the spinal column. Their primary function is to: “absorb shock” from everyday wear and tear; (allow movement of our spinal column, and thus separate the vertebrae. The spinal disc is actually considered a type of cartilaginous joint. Discs consist of an outer annulus fibrosis layer and an inner nucleus pulposis, which is a soft, jellylike substance. The disc is made up of proteins called collagen and proteoglycans that attract water. Normally, discs compress when pressure is put on them, and they decompress when the pressure is relieved. Decompression Therapy works to decompress utilizing a traction correlative and a specific degree protocol to create the event called decompression. Discs are avascular, meaning discs do not have a blood supply, and they exchange nutrients by a process called “imbibition.” Imagine a sponge with water; when you compress the sponge you release water. When you remove the compressive force, water is absorbed back into the sponge. This is exactly how discs work, and it highlights the importance of healthy discs. Diseased discs are a form of DDD, which area sequelae to arthritis, herniated disc, facet syndrome, and spinal stenosis.
Herniation describes an abnormal condition of an intervertebral disc that years ago when I was growing up also referred to as a “slipped” disc, or “blown” disc. These are not medical terms and are not used in the medical world. Scientists for years have searched for a specific cause. However, it is not specifically known what causes any disc to herniate, but research outlines common causes such as,
1. trauma;
2. repetitive stress due to lifestyle, athletics, occupation, poor posture, or other external factors; and
3. the natural processes of aging. The process of herniation occurs when the inner nucleus pulposis bulges through the annulus fibrosis, causing a protruding disc that may push on a spinal nerve. DDD is a progressive disease.
This is why early detection is important. Once the cycle of degeneration begins if treatment is not available to possibly halt the degenerative cycle, the condition will usually continue to manifest itself. Degeneration is a form of progression, once it begins, it continues, it may progress to the point where the inner material (nucleus pulposis) leaks out of the disc. This is the first serious complication. Once the disc has leakage, the body mounts an autoimmune response to the disc material (nucleus pulposis). Remember like toothpaste in the eyes, the body utilizes pain as a warning sign, it activates our proprioreceptors. Once this irritation is coupled with inflammation the sequelae of pain and progressive deterioration of the nerve root begin to take place. If the herniated disc is located in the cervical spine (neck), the symptoms can be neck pain with or without radiation. So you can have disc disease without radiation, radiation is usually a sequelae which is associated with arm pain and/or numbness. If the herniated disc is located in the lumbar spine (lower back), the symptoms can be lower back pain, with or without radiation to the legs or numbness.
Once the pain radiates we call this progression into the extremities whether it appears as numbness in the legs or arms is referred to as a “radiculopathy.” It is important to remember that the nerves that exit your spinal cord attach to the skin in your arms and legs (responsible for sensation), muscles in your arms and legs (responsible for movement), and reflexes in your arms and legs. This is why most patients with any type of disc condition, experience associated extremity pain/numbness/tingling and weakness when they have a disc herniation. The MRI is your best diagnostic tool. When done pre decompression therapy, post studies are often recommended, to define and outline improvement. It is not unusual for patients with herniated discs to only complain of extremity (arm/ leg) pain with minimal neck or lower-back pain.
Our goal, our mission is to make a difference. A failed back surgery syndrome is now of epidemic proportions. When someone has a disk and drew where are they going? We know from my prior education that epidurals are not FDA approved for the treatment of back pain or sciatica, we now know that it is utilized off label. We know even Tiger Woods one of the great golfers of all time has already had four back surgeries. John Heard, the father of the movie Home Alone died after back surgery at Stanford University. We as chiropractors must make a difference. The most serious structural injury to me that a chiropractor will treat is a disc injury, let’s be the best at it. We teach this ongoing at the event, thechiroevent. com, at Trump National in Jupiter Florida. One day, one patient, one disc can change our life. Be a leader, be a specialist, be the best.
Authors:
Dr. Eric S. Kaplan, is President of DISC Centers of America, the largest group of Chiropractic clinics in the U.S.A., utilizing Non-Surgical Spinal Decompression. He has worked with two Presidents of the United States and two U.S. Surgeon Generals. He is CEO of Concierge Coaches, www.conciergecoaches.com, the #1 Chiropractic firm in Spinal Decompression and Neuropathy training nationwide. To read some of the research studies, go to DiscCentersofamerica. com. Or email him at [email protected]
Dr. Jason Kaplan is a graduate of PARKER University. Along with his wife Dr. Stephanie Kaplan, they practice in Wellington Florida. Jason is an Instructor for Disc Centers of America, one of the Nations largest collections of doctors specializing in Disc Injuries. He has been recognized and honored by the International Disc Education Association and serves on the Medical Advisory Board for Non-Surgical Spinal Decompression. He teaches technique at the National Certification Program at Life University and is considered a Master on Non Surgical Spinal Decompression. Www.wellingtondisccenter.com.
Retiring completely at 40 years old, Dr. Perry Bard built one of the busiest clinics in the country. With an average of over 20+ New Paying Patients (NPP's) per day (single office) for OVER 4 years (documented) there are very few (if any) doctors that have generated that sheer volume of New Patients for that long.
