Stages of disc herniation

Slipped discs are often caused by excessive strain or pressure on one part of the spine. Things that make slipped discs more likely include:

• Getting older

• Heavy lifting, including having a job where it occurs  repeatedly

• Having a job that involves sitting for a long time or driving for long periods

• Being overweight or obese

• Smoking

• Being involved with contact sports

The four stages of disc herniation

1. A bulging (protruding) disc

The spine consists of bones (vertebrae) that are stacked upon one another. Each vertebra is connected to the other by an intervertebral disc. The intervertebral discs help increase the flexibility of the spine and function as shock absorbers. Each individual intervertebral disc consists of a tough outer fibrous layer surrounding a jelly-like inner layer.

A bulging (protruding) disc is the earliest and mildest of disc prolapses and is sometimes known as an incomplete herniated disc. In this first stage, the jelly-like disc centre (called the nucleus pulposus) starts to move out of its normal position and starts to push or ‘bulge’ near the outer disc shell. This is why it is sometimes known as a bulging disc. Often due to getting older, injury or repeated heavy spinal movements, this usually improves within a few weeks without specific treatment being needed, and may cause little in the way of symptoms.

2. A prolapsed disc

With a prolapsed disc, the disc bulge progresses so that it starts to press more firmly against the outer shell of the disc. At this stage of disc herniation, symptoms typically start to develop such as pain, numbness and tingling because the disc bulge begins to press on one of the nerves next to the disc.

3. An extruded disc

At this stage, unlike the previous two stages, the jelly-like material in the disc starts to push through the firm outer shell and so is no longer contained completely within the disc. This means there is usually an increase in symptom severity such as worsening pain along with tingling, numbness or weakness that may become progressively worse. It is still possible for this type of disc herniation to be treated without the need for surgery.

4. A sequestrated disc

This is the most progressive stage of a disc herniation, and often requires surgical repair. When a slipped disc gets to this stage, the inner disc material comes completely out of the disc shell, and may fully break off from the disc. At this stage, pain may be severe enough to cause someone to have difficulty moving, or they may even become confined to bed as a result.

This depends on the stage of the herniation. If you have a bulging or prolapsed disc and your symptoms are not too severe, simple measures such as staying active, taking painkillers and heat treatment can all help. Long periods of bed rest or being inactive are now no longer recommended, so avoid sitting still for long periods and try to walk or swim to help reduce any pain and stiffness. 

Avoid heavy lifting or any strenuous bending or twisting. Painkillers such as <u>paracetamol</u> and nonsteroidal anti-inflammatory drugs (or NSAIDS for short) may help with symptoms but be sure not to take more than the recommended dose of painkillers. 

Some people find that using ice packs or heat treatments can help ease back pain. However, remember not to put ice or strong heat directly on your skin, as this may damage it and don't use it for more than 15 minutes at a time. Your doctor may also refer you to a physiotherapist who can help strengthen your back muscles and stop them from stiffening up.

For an extruded disc, in addition to painkillers your doctor might also suggest other treatments including injecting long-lasting anaesthetics or steroids into the spine. This can help numb the pain and reduce any swelling, muscle-relaxing drugs or antidepressants drugs as some of these have been shown to help with pain relief. 

With a sequestrated disc, many people require an operation to repair it, as stopping the disc from pressing on a nerve usually relieves the pain. An MRI scan is normally done beforehand to make sure that it is a disc problem causing the pain because if the pain is not caused by a disc, surgery won't help. The operation is called a discectomy and as with any surgical procedure it has potential risks, including bleeding, infection, and having an allergic reaction to the anaesthetic. Newer types of disc surgery are also being developed such as having artificial discs put into the spine to replace any damaged ones.

As a general rule, if you develop severe neck or back pain following an injury you should seek urgent medical attention.

If your symptoms have any of the following associated features, you should seek urgent medical attention:

• Numbness or weakness that extends down both arms or both legs

• Numbness around your genitals or bottom

• Loss of control of your bowels or bladder 

• Fevers or feeling generally unwell

If you do not have any of the above features, you should see your doctor if your back pain has failed to improve after six weeks or if they are associated with swelling, pain worse at night or recent unintentional weight loss. 

A professional massage or manipulation can help ease aches and pains in the back and improve movement. This is best done by a professional who understands anatomy and injury. A sports therapist, physiotherapist, chiropractor or osteopath are all highly trained, with the latter two working specifically with back problems and alignment. They can also advise on stretches to alleviate pain and rehabilitate, and exercises to prevent future back pain or injury.

With sciatica symptoms, once you’re over the initial spasms of pain, stretching out the hamstring muscles at the back of your thighs helps to ease the sciatica with time, and can prevent it in future.

A transcutaneous electrical nerve stimulation (TENS) machine can help relieve pain by providing small electrical impulses to the lower back area, giving a mild tingling sensation and reducing pain signals to the brain. It’s a good idea to try if you have long-term back pain.

Acupuncture has evidence to back its role in short-term relief of chronic back pain, and it may allow a little more movement to encourage further rehabilitation and repair. Tiny needles are inserted into the skin and muscles, which is thought to release natural painkillers in the body called endorphins.

CBT and mindfulness may help to treat the brain’s interpretation of pain, if your back pain lasts several weeks or months. Sometimes our bodies malfunction to continue making us think we’re in pain, even after we’ve recovered from the initial injury. So cognitive behavioural therapy (CBT) or mindfulness can be beneficial in reducing your sensitisation to chronic pain and thereby dampening its impact.

Taking care of your mental health is essential with injuries that are slow to recover, as chronic back pain can take its toll. Consider what you enjoy and what helps you relax – music, reading, catching up with friends – and work on releasing those natural painkillers, the endorphins. Be aware that low mood, anxiety and depression can sometimes set in with chronic pain. See your doctor if you think your condition is affecting your mental wellbeing.

Core strength and conditioning can help with longer term back pain, and help to prevent future injuries. Pilates, yoga and weight training can all help to build up core muscles, including the paraspinal muscles that hug the spine, and flexibility to keep the spine supple. They also improve posture, which helps if you sit at a desk for long periods or have a physical job requiring lots of lifting.

Fortunately, the pain from a herniated disc gets better without treatment for 9 out of 10 people - typically within six weeks although it can take longer than this, and the pain may come back at some point whether or not you have treatment. It's important to learn how to avoid over-straining or damaging your back again and if you have any concerns about back symptoms always discuss these with your healthcare professional.