So is a disc rupture the same as a disc bulge? And what are my options to recovery?
Many people suffer from back pain and sciatica. And many of these people will have one of the discs in their lower back as the culprit of their back problem.
Unfortunately, a variety of terms are used to describe this, often interchangeably even though there are various subgroups within these terms. Common descriptions include “slipped disc”, disc bulge, disc protrusion, disc herniation, and disc rupture.
These terms really all mean the same thing, with the exception being disc rupture, as this does indicate a more damaged disc that frequently has a worse prognosis (at least in the short-medium term).
To better understand how the disc work’s and how disc rupture differs here is a brief description from my earlier article on sciatica (https://absolutehealthperformance.com.au/sciatica-issues-part-1-physiotherapy-melbourne-cbd/):
Disc bulging leading to sciatica
Disc bulging in the lower back would easily be the most common cause of sciatica, particularly in those under the age of 65. Most commonly this is brought about by high volumes of slouched sitting (poor posture in a sitting occupation), or a short term burst of sitting like a long car trip or overseas flight.
Disc problems may also come about after a heavy lift with a forward bend (such as lifting a suitcase or heavy object at work), or a light trivial bend, especially in the morning. Patients often report the onset of back pain with trivial incidents such as rising from the couch, or picking up something like a sock, because 2/3 of the disc has no nerve endings, and so the problem is present without any pain. The trivial incident is usually the ‘last straw’, where the outer third of the cartilage part of the disc (the annulus fibrosis) is stimulated and suddenly pain is felt in a problem which may have been lurking there for far longer, often with stiffness and loss of movement being the only indicators.
As the disc bulge progresses and worsens over time, or with subsequent episodes of back pain, the disc may bulge far enough to compress the nerve and cause referred leg pain (sciatica). Depending on which level in the lower back the disc is bulging (most commonly L4/5 or L5/S1) and the extent of disc bulging the symptoms may refer into the buttock, thigh, shin/calf or even foot. These symptoms may include aching, burning, stabbing, tingling, numbness and other similar sensations, as the experience of pain can vary markedly between individuals.
Disc rupture (extrusion or sequestration)
Disc ruptures tend to have a more severe clinical presentation. And they refer to breaching of the last layer of the annulus fibrosis (the cartilage rings that hold the contain the central nucleus), where the nuclear material is now no longer ‘contained’.
Not all ruptured discs are picked up on imaging like MRI, but when they do the term disc extrusion or disc sequestration is used.
The following are features that commonly (although not always) occur with a disc extrusion or sequestration:
- Often the back pain stops at the point the disc ruptures, and only leg pain is felt
- If back pain is present, it is much less severe than the leg pain
- The leg pain is usually constant and refers below the knee most commonly
- The leg pain is often severe
- The leg pain often worsens with walking, unlike most disc bulges where walking improves the symptoms
- Weakness, numbness and tingling of the leg is common
Even though a disc rupture can present with severe pain the clear majority do get better with time, and the body can resorb the extruded fragment (Chiu et al 2014). I personally had a sequestrated disc when I was 21 years old, and I never had surgery and on MRI scan some years later the fragment was gone (along with the pain!).
Can the McKenzie Method help me if I have a confirmed disc rupture on imaging?
You should always get a McKenzie Assessment, as it is not unusual for imaging to display a disc rupture, and yet the patient rapidly responds to specific exercises aimed at giving immediate relief of pain (for more detail see this previous article https://absolutehealthperformance.com.au/sciatica-issues-part-2-physiotherapy-melbourne-cbd/).
If I am a confirmed ‘non-responder’ to McKenzie direction based exercises, what are my options to get better?
Even in the case of lumbar disc rupture, natural history and time can be very favourable. Most of these disc ruptures will be absorbed by the body, and whilst there is not the rapid recovery of those who respond to McKenzie exercises (typically 2-4 weeks depending on the individual presentation), these problems often resolve over a period of 6-18 months for around 90% of people.
The big problem is that while time can sort the problem, many sufferers are in significant pain with their sleep, work and activity being greatly impacted by sciatica and leg symptoms.
The role of surgery and medication to assist whilst the body heals itself
Medication, usually anti-inflammatory (eg Voltaren or stronger steroids like Prednisolone) or neuropathic drugs (eg. Lyrica) aim to reduce the irritation and nerve pain.
The anti-inflammatory medication aims to ‘mop up’ chemicals released from the disc that are irritating the nerve root, providing chemical stimulation of the leg symptoms. Injections such as a guided (CT scan guided to ensure accurate placement) nerve root injection can also provide significant relief in some people.
Surgery is usually a last resort given that most of these problems will resolve with time. It should be reserved for those who are not coping despite optimising medication, and failing to improve with less invasive options like a nerve root injection.
I have previously described the surgical options in more detail in a previous article attached here (https://absolutehealthperformance.com.au/sciatica-pain-part-3-physiotherapy-melbourne-cbd/).
The best plan of attack to help cope with a ruptured disc
- Determine with certainty that you are in the non-responder group with a specialised McKenzie Method Assessment (should be possible within 2-4 sessions), as you do not want to miss the potential to have a rapidly reversible condition
- Use a lumbar roll, correct sleeping posture and learn which movements and positions you must avoid to allow the symptoms to calm down
- Explore anti-inflammatory and other specific medications (under the guidance of a good GP or surgeon) to see if your symptoms can be ‘calmed down’ substantially as this will obviously affect your decision whether to proceed to more invasive options like surgery or guided nerve root injection
- Once pain/symptoms are manageable, then focus is on carefully increasing function with your work/home duties and exercise goals
For more information about sciatica come and see our McKenzie Method specialist physiotherapist Joel Laing at Absolute Health & Performance in Melbourne’s CBD.
Chiu, C., Chuang, T., Chang, K., Wu, C., Lin, P. and Hsu, W. (2014). The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation, 29(2), pp.184-195.