“Slipped disc” (Herniated Nucleus Pulposus (HNP)
“Slipped disc” known as a Herniated Nucleus Pulposus (HNP)
In our society, up to 80-85% of the US population will experience low back discomfort of varying causes. You may have heard someone say, “My back has not been too good lately because I have a slipped disc.” What exactly does that mean?
“A slipped disc” refers to an injury to intervertebral disc that is a vital component of the anatomy of the spine that fits in between each bony vertebra. This disc between the vertebrae allows for combination of motion and stability while offering shock absorption during various low back activities.
In the diagram above, the outer layers of the disc called the annular fibrosus can tear which would allow the gel-like center of the disc to be displaced. As the disc material become displaced, this material can intrude and put pressure/compression upon the corresponding nerve root. In medical terms, this is called a herniated nucleous pulposus (HNP).
Usually, an HNP in the lumbar spine will occur in only 5% of the population as it typically effects 30-50 year olds, but can cause significant discomfort at the low back region as well as pain, numbness, tingling or burning sensations into one or both legs. It can also cause weakness and sensory disturbances which correspond to the muscles and skin associated with that specific nerve root being compressed by the HNP.
WHAT YOU WANT TO HAPPEN
Good, proper progress during a specific therapeutic activity would be defined if the intensity, frequency, or duration of the leg discomfort would diminish while moving up the leg toward the spine. This improvement would be called “centralization.” PERFORM EXERCISES OR STRETCHES THAT CAUSE CENTRALIZATION.
WHAT YOU DON’T WANT TO HAPPEN
If an activity creates more intense leg discomfort and greater symptoms further down the leg, that activity should be avoided. Such “peripheralization” of HNP symptoms in the leg will not assist in your recovery. AVOID EXERCISES OR STRETCHES THAT CAUSE PERIPHERALIZATION.
Conservative treatment options include:
- Proper amount of rest during to reduce pressure on the nerve root. However, most clinicians DO NOT advocate complete bed rest.
- DO NOT from extreme turning, twisting, bending activities as such movements will most likely increase disc pressure which could further displace the disc, putting more compression on the nerve root.
- DO NOT lift objects with rotational motions such as placing heavy, wet clothes from the washer to the dryer.
- LIE IN A SUPINE POSITION (called 90-90 position) with your knees and hips each at a 90 degree angle will offer relief as that position will place the lowest stress on the disc.
- PERFORM “POSITIONAL TRACTION” for temporary relief where a specific lumbar spine position can reduce the HNP pressure on the disc which would decrease the intensity of the discomfort in the low back and leg(s) as well as the amount of radiating pain down the leg.
- USE HEAT OR ICE ON YOUR LOW BACK as these non-pharmacological agents while in the 90-90 position mentioned above with proper layers of cloth to maintain your skin integrity and health.
- UNDER ADVICE OF PHYSICIAN Potentially use NSAIDs or other anti-inflammatory medications as directed by your physician.
- Consider participation in formal physical therapy. A physical therapist will be able to assist you in your recovery with a hands-on approach (manual techniques) and symptom management techniques. A physical therapist can more effectively and efficiently create a plan that will take into account your individual impairments. This program should also include supervised exercises performed in the clinic with the correct form while also giving you a home exercise program to follow.
- Home Exercises: Initially, you should perform gentle flexibility and stretching exercises for the low back and legs while later incorporating strengthening of the lumbar spine and core (abdominal muscles).
VERY IMPORTANT: Any exercise should be performed in a relatively pain-free manner with the correct form AS QUALITY IS MORE IMPORTANT THAN QUANTITY. For example, the “no pain no gain” motto DOES NOT apply to this condition. You can have a strong stretch or a sense of muscular fatigue, but you SHOULD NOT have an increase of symptoms like sharp low back pain or a cause or increase in leg pain.
Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med2017;10:507–16.
Guinto FC, Jr, Hashim H, Stumer M. CT demonstration of disk regression after conservative theraphy. AJNR Am J Neuroradiol 1984;5:632–3.
Isner-Horobeti M.-E., Dufour S. P., Schaeffer M., et al. High-force versus low-force lumbar traction in acute lumbar sciatica due to disc herniation: a preliminary randomized trial. Journal of Manipulative and Physiological Therapeutics. 2016;39(9):645–654. doi: 10.1016/j.jmpt.2016.09.006.
Kim E, et al. Effectiveness and safety of acupotomy for lumbar disc herniation: a study protocol for a randomized, assessor-blinded, controlled pilot trial. Integr Med Res. 2017 Sep; 6(3):310-316.
Kim SG, Yang JC, Kim TW. Spontaneous regression of extruded lumbar disc herniation: three cases report. Korean J Spine 2013;10:78–81.
Koes B et al. Diagnosis and treatment of sciatica. BMJ 2007; 334: 1313 – 1317.
Komori H, Shinomiya K, Nakai O, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine 1996;21:225–9.
Kreiner DS, et al, North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan; 14(1):180-91.
Ryu SJ, Kim IS. Spontaneous regression of a large lumbar disc extrusion. J Korean Neurosurg Soc2010;48:285–7.
Tang S., Mo Z., Zhang R. Acupuncture for lumbar disc herniation: A systematic review and meta-Analysis. Acupuncture in Medicine. 2018;36(2):62–70. doi: 10.1136/acupmed-2016-011332.
Turk O et al. Spontaneous regression of herniated nucleus pulposus. The clinical findings of 76 patients. Medicine (Baltimore) 2019 Feb; 98 (8): e14667.
Yang H, Liu H, Li Z, Zhang K, Wang J, Wang H, Zheng Z. Low back pain associated with lumbar disc herniation: role of moderately degenerative disc and annulus fibrous tears. Int J Clin Exp Med. 2015; 8(2):1634-44.
Yang X, Zhang Q, Hao X, et al. Spontaneous regression of herniated lumbar discs: report of one illustrative case and review of the literature. Clin Neurol Neurosurg 2016;143:86–9.