Back Clinic Chronic Back Pain Team. Chronic back pain has a far-reaching effect on many physiological processes. Dr. Jimenez reveals topics and issues affecting his patients. Understanding the pain is critical to its treatment. So here we begin the process for our patients in the journey of recovery.
Just about everyone feels pain from time to time. When you cut your finger or pull a muscle, pain is your body’s way of telling you something is wrong. Once the injury heals, you stop hurting.
Chronic pain is different. Your body keeps hurting weeks, months, or even years after the injury. Doctors often define chronic pain as any pain that lasts for 3 to 6 months or more.
Chronic back pain can have real effects on your day-to-day life and your mental health. But you and your doctor can work together to treat it.
Do call upon us to help you. We do understand the problem that should never be taken lightly.
Many individuals utilize the lower half of their bodies to go to different places and use the various surrounding muscles that provide stability on the hips and low back while supporting the upper body’s weight. Along the lower back is the buttock region, where the gluteal muscles help stabilize the pelvis, extend the hips, and rotate the thighs. The gluteal muscles also help shape and support the spine and have an erect posture in the body. One of the gluteal muscles that support the lower body is the gluteus medius, which can succumb to injuries and strain when overused or strained. This leads to developing trigger points that can cause various issues in the lower extremities and lead to corresponding chronic conditions. Today’s article focuses on the gluteus medius muscles, how the lumbago is associated with gluteus medius trigger pain, and various techniques to manage trigger points along the gluteus medius muscle. We refer patients to certified providers who incorporate multiple methods in the lower body extremities, like butt and low back pain treatments related to trigger points, to aid individuals dealing with pain symptoms along the gluteus medius muscles near and surrounding the body’s lower extremities. We encourage and appreciate patients by referring them to associated medical providers based on their diagnosis, especially when it is appropriate. We understand that education is an excellent solution to asking our providers complex questions at the patient’s request. Dr. Jimenez, D.C., utilizes this information as an educational service only. Disclaimer
Have you been experiencing pain near your buttock and lower back? Have you been feeling unstable when you are walking? What about feeling pain in your tailbone that makes it unbearable to sit down? Many of these issues are associated with referred pain caused by trigger points affecting the gluteus medius. As part of the gluteal muscle region, the gluteus medius lies between the gluteus maximus and minimus is a flat, triangular muscle and is the primary hip abductor. The gluteus medius and minimus work together for internal rotation for the thighs and lateral rotation for the knees when they are extended. The gluteus medius muscles also help stabilize the pelvis, while the trunk maintains an upright position when the legs are in motion. Studies reveal that the gluteus medius is a key lateral hip muscle that correlates with muscle function with other muscle groups like the quadriceps and abdominal muscles. When injuries or not activating the gluteal muscles often, various muscle issues can cause problems to the gluteus medius muscles.
Lumbago Associated With Gluteus Medius Trigger Pain
Dysfunction in the hips can lead to various issues that can either be acute or chronic, depending on how severely the muscles have been overused or injured. Studies reveal that low back pain has been identified as the leading contributor to disability and when there is dysfunction in the lumbopelvic-hip complex, causing a reduction in gluteus medius strength. When the gluteus medius muscles have become overused or injured through trauma, it can develop trigger points on the muscle causing low back pain issues. When trigger points affect the gluteus medius, additional studies reveal that latent trigger points along the gluteus medius muscles may cause joint movement limitation while causing overload by affecting muscle activation from the hips.
According to Dr. Janet G. Travell, M.D.’s book, “Myofascial Pain and Dysfunction: The Trigger Point Manual,” patients with active trigger points along their gluteus medius complain of pain when they are doing normal actions like walking or sitting. The pressure from the trigger points along the gluteus medius causes the individual to be in a slumped position, causing them to be uncomfortable. This causes instability in the hips and lower body extremities, making many people miserable. The book also explains that the referred pain patterns caused by gluteus medius trigger points can overlap other chronic conditions like sacroiliac joint dysfunction, low back pain, and inflammation of the subgluteus medius bursa.
Trigger Point Of The Week: Gluteus Medius- Video
Have you been dealing with hip pain? Do you feel uncomfortable pain when walking or sitting down? Or Do you feel muscle stiffness or tenderness near your tailbone constantly? If you have been experiencing these painful symptoms constantly in your lower back or your hips, it could be due to your gluteus medius muscles being affected by trigger points. The video above overviews the gluteus medius location and how trigger points or myofascial pain syndrome causes referred pain to the lower back and hips. When trigger points affect the gluteus medius, the referred pain can overlap and correlate to low back and hip pain, thus causing various issues to the muscles surrounding the low back and buttock region. Regarding trigger points affecting the gluteus medius, they can be treatable through multiple techniques specific to the low back, buttocks, and hips.
Various Techniques For Managing Trigger Pain Along The Gluteus Medius
When issues of low back or hip pain begin to cause a problem in the lower extremities, the gluteus muscles can invoke pain-like symptoms in the affected muscle regions, thus developing trigger points. Even though trigger points are tricky to diagnose, they can be treated with various techniques that many people can incorporate into their daily lives. Exercises like resistance training on the gluteus medius can help improve hip abductor functionality and increase the strength of the gluteus medius. To manage trigger points along the gluteus medius, many people must do these corrective actions to reduce the pain that they may be causing to their glutes. When people are putting on pants, it is best to sit down and then put on their pants to prevent muscle strain on their hips and gluteus medius. Another corrective action is to move around after sitting down for a prolonged period to avoid trigger pain from developing. These corrective actions and techniques can help strengthen the lower body extremities and improve hip mobility.
As part of the gluteal muscle region, the gluteus medius lies between the gluteus maximus and minimus by being a primary hip abductor. The gluteus medius helps with pelvic stabilization and helps the trunk maintain an upright position when the legs are in motion. When normal or traumatic factors affect the gluteus medius, it can develop trigger points on the muscle fibers, causing referred pain to the hips and lower back. Trigger points along the gluteus medius are manageable through various techniques that people can use to prevent hip and low back issues. These techniques can minimize the trigger points and strengthen the gluteus medius muscles in the glutes.
Bagcier, Fatih, et al. “The Relationship between Gluteus Medius Latent Trigger Point and Muscle Strength in Healthy Subjects.” Journal of Bodywork and Movement Therapies, U.S. National Library of Medicine, Jan. 2022, pubmed.ncbi.nlm.nih.gov/35248262/.
Shah, Aashin, and Bruno Bordoni. “Anatomy, Bony Pelvis and Lower Limb, Gluteus Medius Muscle.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 25 Jan. 2022, www.ncbi.nlm.nih.gov/books/NBK557509/.
Stastny, Petr, et al. “Strengthening the Gluteus Medius Using Various Bodyweight and Resistance Exercises.” Strength and Conditioning Journal, Strength and Conditioning Journal, June 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4890828/.
Travell, J. G., et al. Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 2:the Lower Extremities. Williams & Wilkins, 1999.
Whiler, Lisa, et al. “Gluteus Medius and Minimus Muscle Structure, Strength, and Function in Healthy Adults: Brief Report.” Physiotherapy Canada. Physiotherapie Canada, University of Toronto Press, 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5963550/.
Back pain is one of the most common reasons individuals go to a doctor, massage therapist, physiotherapist, osteopath, and chiropractor. Various health conditions, some spine-related, others not, list back pain as a symptom. Many of these conditions begin in the stomach or abdominal cavity, which leads to stomach and back pain. Stomach and back pain happening simultaneously, independently, or in combination could be caused by gut problems, back issues, or something completely different. Understanding what causes these two types of pain simultaneously can help figure out a treatment plan.
Stomach Back Pain Causes
Problems in the abdominal cavity and stomach issues can cause back pain and vice versa. Symptoms can also include referred pain when the pain is felt in one part of the body but is caused by pain or injury in another area. Stomach back pain causes depend on the type of condition/s that can include:
Inflammation in the appendix can cause sudden sharp pain in the abdomen.
It presents mostly in the lower right area of the abdomen but can appear in or spread to other sites, especially the back.
A chiropractic functional medicine team can work with an individual’s primary physician or specialist to develop a personalized treatment plan to alleviate back pain symptoms, re-balance the body, strengthen the musculoskeletal system and restore function.
Krames E, Mousad DG. Spinal Cord Stimulation Reverses Pain and Diarrheal Episodes of Irritable Bowel Syndrome: A Case Report. Neuromodulation. 2004 Mar 22;7(2):82-88. doi.org/10.1111/j.1094-7159.2004.04011.x
Weisman, Michael H et al. “Axial Pain and Arthritis in Diagnosed Inflammatory Bowel Disease: US National Health and Nutrition Examination Survey Data.” Mayo Clinic proceedings. Innovations, quality & outcomes vol. 6,5 443-449. 16 Sep. 2022, doi:10.1016/j.mayocpiqo.2022.04.007
Whorwell PJ. Chapter 13, Abdominal Bloating. Irritable Bowel Syndrome: Diagnosis and Clinical Management. Emmanuel A, Quigley EMM (eds.). John Wiley & Sons; 2013. doi.org/10.1002/9781118444689.ch13
When it comes to the torso is surrounded by various muscles that help protect the vital organs known as the gut system and help with stabilizing the spinal column in the body. The abdominal muscles are essential to maintaining good posture and core support for many individuals. When normal activities or chronic issues begin to affect the body, the abdominal muscles can also be affected and can cause referred pain all around the torso area. When the abdominal muscles are dealing with referred pain, it can develop into trigger points that mask other chronic conditions affecting the torso and the thoracolumbar region. Today’s article looks at the abdominal muscles and their function, how trigger points are affecting the abdomen, and how various treatments help manage trigger points associated with abdominal pain. We refer patients to certified providers who provide different techniques in abdominal pain therapies related to trigger points to aid many suffering from pain-like symptoms along the abdominal muscles along the torso. We encourage patients by referring them to our associated medical providers based on their examination when it is appropriate. We designate that education is a great solution to asking our providers profound and complex questions at the patient’s request. Dr. Alex Jimenez, D.C., notes this information as an educational service only. Disclaimer
Do you have trouble moving around? Have you been dealing with muscle spasms along your abdomen? Does it hurt when you are sneezing, laughing, or coughing constantly? All these actions affecting your abdominal muscles might correlate with trigger points along the muscles and disrupt the torso area. The abdomen in the body has various muscles, a complex organ with many functions that contribute to a person’s quality of life. The abdominal muscles have many important parts, from supporting the trunk, allowing movement like twisting and turning, and holding the organs in the gut system in place through internal abdominal pressure regulation. The abdominal muscles have five main muscles that work together with the back muscles to keep body stability. They are:
Studies reveal that the abdominal muscles can help increase the stability of the lumbar region of the body from the vertebral columns by tending the thoracolumbar fascia and raising the intra-abdominal pressure. This allows the abdominal muscle to bend and flex in different positions without feeling pain. However, overusing the abdominal muscles can lead to unnecessary issues that can affect not only the torso but the surrounding muscles around the torso.
How Trigger Points Are Affecting The Abdomen
The book “Myofascial Pain and Dysfunction,” by Dr. Janet Travell, M.D., mentioned that abdominal symptoms are common and can cause diagnostic confusion for many people. Since the abdominal muscles can provide stability to the body’s trunk when a person overuses the abdominal muscles through various activities like quick and violent twisting of the mid-section, lifting heavy objects with the core instead of the legs, overdoing exercise regimes, or having a persistent cough, these various activities could potentially lead to the development of trigger points in the abdominal muscles causing pain in the abdomen and causing referred pain to the lower back. Studies reveal that trigger points along the abdominal muscles are developed through aggravating factors like prolonged sitting or standing can cause the abdominal muscles to become extremely tender and hyperirritable along the taut muscle bands. When trigger points affect the abdominal muscles, they can produce referred abdominal pain and visceral disorders (somato-visceral effects) that work closely together to mimic visceral diseases. This pertains to many individuals thinking something is wrong in their gut system, but their abdominal muscles are causing issues in their bodies.
Releasing Trigger Points In The Abdominal Muscles-Video
Have you been experiencing abdominal issues around your torso? Does it hurt when you laugh, cough, or sneeze? Do you feel muscle stiffness or tenderness along your abdominals? If you have been dealing with these symptoms throughout your life, you could be experiencing abdominal pain associated with trigger points in your torso. Abdominal pain is common for many individuals and can vary from gut issues or muscle issues that various factors can cause in the torso. Abdominal issues can even cause confusion to doctors when they are diagnosing the issues that are affecting their patients. When various actions cause pain to the abdominals, it can develop referred pain associated with trigger points. Trigger points develop when the muscle has been overused, creating tiny nodules in the taut band. Trigger points can be tricky to pinpoint but are treatable. The video above shows where the trigger points are located in the abdominal muscles and how to release them from the affected abdominal muscles to provide relief and reduce the mimic effects of visceral-somatic pain.
Managing Trigger Points Associated With Abdominal Pain Through Various Treatments
When abdominal pain affects the muscles, the symptoms can develop trigger points. When this happens, it can lead to confusion and often misdiagnosed. All is not lost; there are ways to manage trigger points associated with abdominal pain through various treatments. Studies reveal that various therapies like dry needling combined with palpations can reduce trigger points from causing more referred pain issues in the abdomen. Other ways to prevent trigger points from developing in the future are through exercises that can help strengthen the abdominal muscles. Exercises like abdominal breathing, pelvic tilts, sit-ups, and even laughter can help strengthen weak abdominal muscles and positively affect the body.
The torso has various muscles, known as abdominal muscles, that help protect the vital organs in the gut system, help stabilize the spinal column, and maintain good posture for many individuals. Various factors affecting the abdominal muscles can lead to a confusing diagnosis, as it could be an internal or external issue. When the abdominal muscles are affected by being overused through various activities, it can develop into trigger points in the muscles, causing visceral referred pain to the torso and cause muscle weakness. Luckily multiple treatments can help reduce the effects of trigger points associated with abdominal pain and can help strengthen the core of the body. This allows the individual to feel better and consider what not to do to their abdominals.
Rajkannan, Pandurangan, and Rajagopalan Vijayaraghavan. “Dry Needling in Chronic Abdominal Wall Pain of Uncertain Origin.” Journal of Bodywork and Movement Therapies, U.S. National Library of Medicine, Jan. 2019, pubmed.ncbi.nlm.nih.gov/30691770/.
Seeras, Kevin, et al. “Anatomy, Abdomen and Pelvis, Anterolateral Abdominal Wall.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 25 July 2022, www.ncbi.nlm.nih.gov/books/NBK525975/.
Many individuals don’t realize that the various muscles in their back help provide functionality to the body. The back muscles help move, bend, rotate, and help the individual stand up straight when they are out and about. The back muscles also help protect the cervical, thoracic, and lumbar sections of the spine and work together with the head, neck, shoulders, arms, and legs to provide mobility. When the body begins to wear down with age naturally, it can lead to back issues that can limit a person’s mobility, or normal activities can cause the back muscles to be overused and develop trigger points to invoke back pain or lumbago. Today’s article looks at the thoracolumbar paraspinal muscles in the back, how the lumbago is associated with trigger points, and treatments to relieve the lumbago in the thoracolumbar muscles. We refer patients to certified providers who provide different techniques in thoracic lumbar back pain therapies associated with trigger points to aid many suffering from pain-like symptoms along the thoracolumbar paraspinal muscles along the back, causing lumbago. We encourage patients by referring them to our associated medical providers based on their examination when it is appropriate. We designate that education is a great solution to asking our providers profound and complex questions at the patient’s request. Dr. Alex Jimenez, D.C., notes this information as an educational service only. Disclaimer
Have you been finding it difficult to walk even for a short period? Do you feel aches and soreness when getting out of bed? Are you constantly in pain when bending over to pick up items from the ground? These various actions that you are doing incorporate the thoracolumbar paraspinal muscle in the back, and when issues affect these muscles, it can lead to lumbago associated with trigger points. The thoracolumbar paraspinal in the back is a group of muscles closely surrounded by the thoracolumbar spine, where the thoracic region ends, and the lumbar region begins. The thoracolumbar paraspinal muscles in the back have a casual relationship with the body as it requires contribution from the systems requiring movement. Studies reveal that the thoracolumbar paraspinal muscles are modulated through communication with the three sub-systems, which include:
The passive system: vertebrae, discs, and ligaments
The active system: muscles and tendons
The control system: central nervous system and nerves
Each system provides muscular activities when a person is bending down to pick up an object or doing simple movements. However, when the muscles become overused, it can lead to various issues affecting the back and surrounding muscles.
Lumbago Associated With Trigger Points
Studies reveal that paraspinal muscle integrity plays a very critical role when it comes to the maintenance of spinal alignment in the back. When the thoracolumbar paraspinal muscles become overused from normal activities, it can affect the back by causing back pain symptoms or lumbago associated with trigger points. In Dr. Travell, M.D.’s book “Myofascial Pain and Dysfunction,” trigger points may be activated due to sudden movements or sustained muscular contraction over time that leads to the development of lumbago. Atrophy issues in the paraspinal muscles can contribute to lumbago associated with trigger points that cause deep referred pain in the thoracolumbar regions of the back. Active trigger points in the deep muscle group of the thoracolumbar paraspinal can impair movement between the vertebrae during flexion or side bending.
An Overview Of Lumbago- Video
Lumbago or back pain is one of the most common issues that many individuals, from acute to chronic, depending on how severe the pain is inflicted on the back. Have you been feeling pain in your mid-lower back? Do you feel an electric shock when you run down your leg in a weird position? Or have you felt tenderness in the middle of your back? Experiencing these symptoms could indicate that the thoracolumbar paraspinal muscles are affected by trigger points associated with lumbago. The video explains what lumbago is, the symptoms, and various treatment options to relieve the pain and manage trigger points that are causing the thoracolumbar muscles issues in the back. Many individuals who suffer from lumbago don’t often realize that various factors can affect the surrounding muscles in the thoracolumbar region and mask other previous conditions from which they could suffer. Regarding managing lumbago associated with trigger points, various treatment options can help reduce the pain affecting the thoracolumbar paraspinal muscles while managing trigger points for progressing further in the back.
Treatments To Relieve Lumbago In The Thoracolumbar Muscles
Since lumbago or back pain is a common issue for many people, various treatments can reduce the pain-like symptoms in the thoracolumbar muscles and manage the associated trigger points. Some of the simplest treatments that many individuals can use are to correct how they are standing. Many individuals often lean on one side of their bodies which causes the thoracolumbar paraspinal muscles on the opposite sides to be overloaded. This causes spinal subluxation or misalignment to the thoracolumbar region. Another treatment that many people can incorporate into their daily lives is by going to a chiropractor for a spinal adjustment for the thoracolumbar spine. Studies reveal that chiropractic care combined with physical therapy can relieve the thoracolumbar back while reducing the pain symptoms associated with trigger points by loosening the stiff muscles and causing relief to the back.
The back has various muscles known as the thoracolumbar paraspinal muscles that allow movement and mobility to the body. The back muscles help protect the cervical, thoracic, and lumbar sections of the spine while working with the rest of the body’s components to keep the body stable. When natural aging or actions affect the back muscles, it can lead to various pain issues that can activate trigger points causing lumbago or back pain. Fortunately, some treatments can help alleviate back pain in the thoracolumbar paraspinal muscles while managing trigger points to bring back mobility to the back.
du Rose, Alister, and Alan Breen. “Relationships between Paraspinal Muscle Activity and Lumbar Inter-Vertebral Range of Motion.” Healthcare (Basel, Switzerland), MDPI, 5 Jan. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4934538/.
He, Kevin, et al. “The Implications of Paraspinal Muscle Atrophy in Low Back Pain, Thoracolumbar Pathology, and Clinical Outcomes after Spine Surgery: A Review of the Literature.” Global Spine Journal, SAGE Publications, Aug. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7359686/.
Khodakarami, Nima. “Treatment of Patients with Low Back Pain: A Comparison of Physical Therapy and Chiropractic Manipulation.” Healthcare (Basel, Switzerland), MDPI, 24 Feb. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7151187/.
Travell, J. G., et al. Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 1:Upper Half of Body. Williams & Wilkins, 1999.
As the “backbone” of the body, the thoracic region of the back has various muscles that help support the ribcage and protect the heart and lungs from injuries. The thoracic spine’s main function is providing respiration and maintaining good posture. However, various habits can cause issues to the muscles in the thoracic spine, which leads to upper back pain and the development of trigger points. One of the thoracic muscles affected by trigger points is the serratus posterior inferior muscle. Today’s article looks at the serratus posterior inferior muscle, how trigger points affect the thoracic region of the back, and how to manage thoracic back pain associated with trigger points. We refer patients to certified providers who provide different techniques in thoracic back pain therapies associated with trigger points to aid many suffering from pain-like symptoms along the serratus posterior inferior muscle along the back. We encourage patients by referring them to our associated medical providers based on their examination when it is appropriate. We designate that education is a great solution to asking our providers profound and complex questions at the patient’s request. Dr. Alex Jimenez, D.C., notes this information as an educational service only. Disclaimer
Have you felt aches and pain when bending down to pick something up? What about feeling tenderness near your lower back? Or have you experienced muscle stiffness when stretching? Many of these symptoms are associated with back pain that correlates to overusing the thoracic muscles, which includes the serratus inferior posterior muscles. The serratus posterior muscles (superior and inferior) are accessory breathing muscles as part of the extrinsic muscles. The serratus posterior inferior helps with the chest cavity’s expiration, while the superior help with inspiration. Some of the functionalities that the serratus posterior inferior provides are that in a bilateral action, the inferior works with the superior muscles to reduce the extension of the thoracic vertebrae.
In contrast, the unilateral action for the serratus posterior inferior muscle helps rotate the spine to the opposite sides. Studies reveal that based on the attachment of the serratus, the posterior inferior and superior are generally considered insignificant muscles. Since the serratus posterior muscles help aid respiration to the thoracic region, it can be succumbed to trigger points or myofascial pain syndrome that can affect the thoracic part of the back.
How Trigger Points Affect The Thoracic Region?
When the serratus posterior muscles in the thoracic region are affected by myofascial pain syndrome or trigger points, it correlates to the various activities the person has been doing that cause muscle strain along the serratus inferior posterior muscle. The book, “Myofascial Pain & Dysfunction” explains that when individuals feel a nagging ache in the lower thoracic region of the back, it correlates to residual backache associated with trigger points. Studies reveal that trigger points or myofascial pain syndrome are musculoskeletal pain disorder that affects one or multiple muscles in the body. Since back pain is common, trigger points can cause hyperirritability in the muscle’s taut band due to various factors that can cause strain on the affected muscle. When it comes to the serratus posterior inferior muscle developing active trigger points, it’s due to overload strain from combined movements like lifting, turning, and reaching for items that can also affect the surrounding muscles in the thoracic region of the back.
Trigger Point Of The Week: Serratus Posterior Inferior- Video
Have you been dealing with pain in your upper back in the thoracic region? Do you experience tenderness or soreness near your ribcage? Or have you felt a twinge of pain when turning your torso? Most of these symptoms are common signs that the thoracic region is affected by trigger points along the serratus posterior inferior muscle. The video explains where the serratus posterior inferior is located while pinpointing where the trigger points are located in the thoracic region of the back. Trigger points associated with thoracic back pain mimic other chronic conditions that can cause muscle tension and strain on the upper back. Studies reveal that latent and active trigger points affecting the upper thoracic area muscles can make many individuals feel more pain than they can tolerate. This can affect how a person functions and can make them feel inadequate. However, it is possible to incorporate a variety of treatments to reduce the pain and manage trigger points from progressing further in the thoracic region of the back.
Managing Thoracic Back Pain Associated With Trigger Points
Various treatments are available to reduce the pain affecting the thoracic region of the back and even manage trigger points associated with the serratus posterior inferior muscle. Many individuals often go to a chiropractor to relieve their back pain. Chiropractors utilize their hands and various techniques to manipulate the spine and can even pinpoint where the trigger points affect the multiple muscles in the thoracic region. Chiropractors even work with other pain specialists to devise a treatment procedure to reduce the symptoms while managing thoracic back pain associated with trigger points. Studies reveal that by when pain specialists like chiropractors begin identifying proper treatment strategies for managing thoracic back pain associated with trigger points, it might be able to reduce pain and improve function for many people dealing with thoracic back pain.
The thoracic region of the back has various muscles that help support the ribcage and protect vital organs, which include the heart and the lungs. One of the muscles in the thoracic region is the serratus posterior inferior muscle, an accessory breathing muscle that helps with the chest cavity expiration and helps reduce the extension of the thoracic vertebrae. When the inferior muscle becomes overused by various movements, it can develop trigger points along the inferior muscle, causing thoracic back pain. Trigger points along the serratus inferior posterior muscles can mimic other chronic conditions that can cause symptoms of muscle tension and strain on the upper back. Luckily, various treatments have been available to reduce pain symptoms and manage thoracic back pain associated with trigger points. These treatments can bring back mobility to the thoracic region of the back without the individual being in pain.
Dor, Adi, et al. “Proximal Myofascial Pain in Patients with Distal Complex Regional Pain Syndrome of the Upper Limb.” Journal of Bodywork and Movement Therapies, U.S. National Library of Medicine, July 2019, pubmed.ncbi.nlm.nih.gov/31563368/.
Mitchell, Brittney, et al. “Anatomy, Back, Extrinsic Muscles.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 25 Aug. 2022, www.ncbi.nlm.nih.gov/books/NBK537216/.
Ortega-Santiago, Ricardo, et al. “Widespread Pressure Pain Sensitivity and Referred Pain from Trigger Points in Patients with Upper Thoracic Spine Pain.” Pain Medicine (Malden, Mass.), U.S. National Library of Medicine, 1 July 2019, pubmed.ncbi.nlm.nih.gov/30821833/.
Travell, J. G., et al. Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 1:Upper Half of Body. Williams & Wilkins, 1999.
Vilensky , J A, et al. “Serratus Posterior Muscles: Anatomy, Clinical Relevance, and Function.” Clinical Anatomy (New York, N.Y.), U.S. National Library of Medicine, July 2001, pubmed.ncbi.nlm.nih.gov/11424195/.
The upper back is part of the thoracic region of the spine, surrounded by various muscles that protect the thoracic joints and help assist with respiratory functionality for the lungs. The upper back muscles consist of the rhomboids and the trapezoid muscles that provide functionality to the scapula or shoulder blades. Other superficial muscles offer assistance to the thoracic spine. The serratus posterior muscle is one of the superficial muscles that helps the thoracic spine and, like all superficial muscles, can succumb to injuries that can lead to the development of overlapping referred pain symptoms known as trigger points. Today’s article focuses on the serratus posterior muscle function in the back, how trigger points are causing upper back pain, and various techniques to manage trigger points in the upper back. We refer patients to certified providers who are diverse in upper back pain therapies to aid many people suffering from myofascial pain syndrome or trigger points associated with the serratus posterior muscle along the upper back. We advised patients by referring them to our associated medical providers based on their examination when appropriate. We indicate that education is a great solution to asking our providers profound and complex questions at the patient’s request. Dr. Alex Jimenez, D.C., notes this information as an educational service only. Disclaimer
The Serratus Posterior Muscle Function In The Back
Have you been dealing with constant upper back pain? Do you feel soreness at the base of your neck? Or are you having difficulty breathing? Most of the symptoms cause pain in the serratus posterior muscles that can lead to the development of myofascial pain syndrome or trigger points along the upper back. The serratus posterior has various roles in the upper back as it is not only part of the extrinsic muscles but also part of the accessory breathing muscle. The serratus posterior muscle helps with inspiration, which causes the chest cavity to expand as it is a superficial muscle attached to the ribs and is less commonly known. Studies show that the serratus posterior muscle is deep within the rhomboid muscles and is superficial. Even though this muscle is superficial when it has been overused through various activities, that can cause hypertrophy in the accessory respiratory muscles. Additional studies reveal that the serratus posterior superior muscle is considered clinically insignificant but has been impaired by myofascial pain syndrome or trigger points that can lead to upper back pain.
Trigger Points Causing Upper Back Pain
As stated earlier, the upper back is part of the thoracic region of the spine, and when various factors begin to affect the body, the back muscles tend to be involved. Studies reveal numerous sources of spinal pain in the thoracic spine. One is a myofascial pain syndrome affecting the serratus posterior muscles causing referred upper back pain. Myofascial pain syndrome or trigger points can be activated when the serratus posterior muscle is overloaded from thoracic respiratory issues like coughing due to pneumonia, asthma, or chronic emphysema. When respiratory problems affect the muscles in the thoracic region of the back, it leads to the development of trigger points, leading to overlapping issues like referred pain, motor dysfunction, and autonomic phenomena. According to Dr. Travell, M.D., in the upper back, trigger points can make the serratus posterior muscle cause overlapping risk profiles along the shoulder blades and have referred pain travel to the hands. This can make many individuals suffer from serious pain-like symptoms, causing them to be miserable.
Releasing Trigger Points Related Tension In The Upper Back-Video
Have you been dealing with respiratory issues causing you to be hunched over constantly? Do you feel soreness or tenderness at the base of your neck? Or are you suffering from upper back pain? These symptoms are associated with trigger points that are affecting the serratus posterior muscles causing upper back pain. Trigger points, or myofascial pain syndrome, is a musculoskeletal disorder that causes tenderness along the affected muscle that causes referred pain to the surrounding muscles in the body. Trigger points associated with the serratus posterior muscles can cause referred pain in the upper back and mimic various chronic conditions. Trigger point pain is difficult to diagnose but can be manageable with treatment. The video above gives examples of how to treat trigger points to relieve tension in the upper back.
Various Techniques To Manage Trigger Points In The Upper Back
When it comes to upper back pain, many individuals will go to pain specialists like massage therapists or chiropractors to relieve any issues affecting the upper back. These pain specialists utilize various techniques like stretching, spinal manipulation, massages, and ischemic compression to alleviate pain and manage trigger points from forming further in the affected muscle. Pain specialists like massage therapists or chiropractors are excellent for locating pain-like symptoms associated with trigger points. Even though treatment can help manage symptoms associated with trigger points, many people can still incorporate these techniques, like deep breathing or correcting their posture, to prevent the upper back muscles from becoming strained and causing more issues than before.
The serratus posterior muscles have various roles in the upper back region of the body. These superficial muscles are extrinsic and accessory breathing muscles that help expand the chest cavity. When multiple issues affect the upper back muscles, like strenuous activities or respiratory problems, it can develop trigger points along the serratus posterior muscles and invoke pain-like symptoms to travel down to the hand, causing mobility issues. Thankfully, various techniques that pain specialists like chiropractors and massage therapists use can help manage trigger points from escalating and can bring upper back mobility to the body once again.
Briggs, Andrew M, et al. “Thoracic Spine Pain in the General Population: Prevalence, Incidence and Associated Factors in Children, Adolescents and Adults. A Systematic Review.” BMC Musculoskeletal Disorders, BioMed Central, 29 June 2009, www.ncbi.nlm.nih.gov/pmc/articles/PMC2720379/.
Mitchell, Brittney, et al. “Anatomy, Back, Extrinsic Muscles.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 4 Aug. 2021, www.ncbi.nlm.nih.gov/books/NBK537216/.
Travell, J. G., et al. Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 1:Upper Half of Body. Williams & Wilkins, 1999.
Vilensky, J A, et al. “Serratus Posterior Muscles: Anatomy, Clinical Relevance, and Function.” Clinical Anatomy (New York, N.Y.), U.S. National Library of Medicine, July 2001, pubmed.ncbi.nlm.nih.gov/11424195/.
Spondyloarthritis is a group of inflammatory, immune-mediated diseases that cause chronic low back pain, inflammation, irritating aches, and pains. The conditions mostly affect the spine but can affect joints in the arms, legs, hips, skin, eyes, and intestines. Spondylitis types can significantly affect daily function, physical activity and compromise bone health.
The main types include:
Axial Spondylitis vs. Peripheral Spondylitis Types
Axial means relating to the body’s central region, as in the trunk and head.
Axial spondyloarthritis is arthritis and inflammation in the hips and spine.
The condition starts before age 45.
The pain typically starts in the low back but can begin in the neck or other regions.
Characterized by back pain, usually in the lower back and/or buttocks.
Morning back stiffness lasting 30 minutes or longer.
Sacroiliac joint inflammation can also present.
The back pain gradually progresses.
Lasts longer than three months.
Improves with physical movement, not with rest.
Peripheral spondyloarthritis is arthritis and inflammatory pain in the peripheral joints and tendons and does not include the spine.
Individuals can have peripheral and axial spondylitis symptoms simultaneously.
Diagnosis depends on whether symptoms are primarily peripheral or axial.
Spondylitis and Spondylosis
Spondylosis and spondylitis are similar in they cause pain and inflammation in the back and hips. The difference is in each condition’s triggers.
Spondylitis is a disease in which the body’s immune system degrades joints, causes inflammation, overproduces bone formation, and causes bone fusion.
Spondylosis is a category of arthritis that presents as the spine ages from normal wear and tear.
It happens during the degeneration of the spine’s discs and joints.
It also presents when bone spurs develop on the spine’s vertebrae.
Ankylosing spondylitis is the most common form of arthritis affecting the spine, other joints, and body regions. The condition causes spinal joint inflammation causing extreme discomfort and chronic pain. In some cases, the inflammation progresses to ankylosis, where spine sections fuse and become immobile. Other body areas that can trigger inflammation include:
Small joints of the feet and hands.
Ankylosing spondylitis symptoms vary from person to person. Common early symptoms include:
There is general discomfort, appetite loss, and mild fever early in the condition.
Persistent stiffness and pain in the buttocks and low back, gradually progressing over a couple of weeks or months.
The pain and stiffness can travel into the neck and spine within months or years.
The pain is usually spread out and dull.
The stiffness and pain are worse in the morning and night and improve with light exercise or a warm shower.
The pain typically becomes chronic, lasts for a minimum of 3 months, and can be felt on both sides.
Tenderness and pain in the hips, thighs, shoulder blades, heels, and ribs may also occur.
Treatment approaches include applications of ice and heat to reduce swelling, increase circulation, and decrease joint pain, posture exercises, stretches, physical therapy, and medication.
Psoriatic arthritis causes swelling, pain, and inflammation in the small joints of the hands and feet; however, the joints of the knees, ankles, and wrists can also be affected. Psoriasis is a rash that causes scaly skin patches.
Individuals can develop dactylitis when a finger or toe swells between the surrounding joints.
Spinal stiffness and pain can present.
Typically the ends of the finger joints are most affected and experience pain and inflammation.
Medications frequently utilized to treat ankylosing spondylitis can be used.
Exercise helps preserve the range of motion and maintain strength.
Isometric exercises work muscles without joint motion reducing the risk of further injury to inflamed joints.
Occupational and physical therapy can significantly assist in optimizing arthritic joint function.
Enteropathic Arthritis is chronic inflammatory arthritis linked to inflammatory bowel disease. The most recognized are Crohn’s and ulcerative colitis.
The peripheral limb joints and sometimes the whole spine are the most prevalent body areas afflicted with enteropathic spondylitis.
The main symptom is intestine inflammation, including bowel and joint pain and/or inflammatory back pain.
Other symptoms can include weight loss, blood in the stool, abdominal pain, and/or chronic diarrhea.
Managing enteropathic arthritis typically means managing the underlying bowel disease.
Juvenile spondyloarthritis is a group of childhood rheumatic diseases that cause arthritis before age 16 and can continue through adulthood. Juvenile spondyloarthritis encompasses:
Juvenile ankylosing spondylitis
Juvenile spondyloarthritis causes inflammation and pain in joints in the lower body, like the ankles, hips, knees, and pelvis. Other body areas that could be affected include:
Lethargy and fatigue can also present. The symptoms can be unpredictable and episodic, appearing and disappearing without a specific cause. The condition cycles between flare-ups and remission. Common treatment approaches include:
Physical therapy, medication
Ice and heat to decrease joint pain and relax muscles.
In severe cases, surgery could be recommended.
Reactive Arthritis or Reiter’s Syndrome
Reactive arthritis is arthritis that causes pain and inflammation in the mucous membranes, bladder, skin, joints, eyes, and genitals.
Reactive arthritis is believed to be a reaction to an infection, usually in the gastrointestinal or urinary tract.
Reactive arthritis does not affect the sacroiliac joints and spine in most cases.
Reactive arthritis is typically treated with nonsteroidal anti-inflammatory medications, steroids, and rheumatoid arthritis medications.
A physician could prescribe antibiotics if a bacterial infection brought on reactive arthritis.
Undifferentiated spondyloarthritis is where the signs and symptoms of spondylitis don’t meet the criteria for a specific rheumatoid disorder. Individuals diagnosed with undifferentiated spondyloarthritis will have one or more of the symptoms that include:
Buttock pain that alternates or presents on both sides.
Swollen toes or fingers
Arthritis in the small joints.
Arthritis in the large limb joints.
Enthesitis or inflammation where the ligament or tendon connects to the bone.
Individuals can also present symptoms of other spondylitis types, like psoriatic or ankylosing.
Treatment approaches include:
Ice and heat to decrease joint pain and loosen up muscles.
Spondylitis Types Diagnosis of Spondyloarthritis
Carron, Philippe, et al. “Peripheral spondyloarthritis: a neglected entity-state of the art.” RMD open vol. 6,1 (2020): e001136. doi:10.1136/rmdopen-2019-001136
Gill, Tejpal, et al. “The intestinal microbiome in spondyloarthritis.” Current opinion in rheumatology vol. 27,4 (2015): 319-25. doi:10.1097/BOR.0000000000000187
Rosenbaum, James T. “The eye in spondyloarthritis✰.” Seminars in arthritis and rheumatism vol. 49,3S (2019): S29-S31. doi:10.1016/j.semarthrit.2019.09.014
Seo, Mi Ryoung et al. “Delayed diagnosis is linked to worse outcomes and unfavorable treatment responses in patients with axial spondyloarthritis.” Clinical rheumatology vol. 34,8 (2015): 1397-405. doi:10.1007/s10067-014-2768-y
Sharip, Aigul, and Jeannette Kunz. “Understanding the Pathogenesis of Spondyloarthritis.” Biomolecules vol. 10,10 1461. 20 Oct. 2020, doi:10.3390/biom10101461
Many individuals do not realize they are in pain until they begin to feel symptoms of stiffness or tenderness in certain areas of their body. Many people have two most common complaints: back and shoulder pain. The shoulder and the back have a casual relationship that stabilizes the upper body and protects the spine’s thoracic region. When injuries or ordinary factors affect not only the shoulders but the back, it can lead to symptoms of pain and stiffness along the muscles, causing the development of trigger points along the upper back and shoulder muscles. One of the muscles affected by trigger points is the rhomboid muscles located in the upper back behind the scapula (shoulder blades). Today’s article looks at the rhomboid muscle, how superficial backaches and round shoulders can affect the rhomboid muscle, and managing trigger points associated with the rhomboid muscle. We refer patients to certified providers specializing in back pain treatments to aid individuals suffering from trigger points associated with the upper back along the rhomboid muscles. We also guide our patients by referring them to our associated medical providers based on their examination when appropriate. We ensure that education is a great solution to asking our providers insightful questions. Dr. Jimenez DC observes this information as an educational service only. Disclaimer
Do muscle stiffness in your shoulders seem to be causing you pain? Have you noticed that your shoulders seem more rounded than usual? What about the unexplainable upper backaches after being in a hunched position for a long period? Many individuals with these pain symptoms could be associated with the rhomboid muscles. The rhomboid muscles are a collective group of muscles important for upper limb movement and stability for the shoulder’s girdle and scapula. The rhomboid muscles consist of two separate muscles: the rhomboid minor and the rhomboid major, deep within the trapezius muscle and behind the scapula (shoulder blades). The functionality of the rhomboid is that they provide stability to the shoulder and when they are active, the upper arms move back and forth while walking.
How Superficial Backaches & Round Shoulders Affect The Rhomboid
While the rhomboid muscles provide stability to the shoulders, they can succumb to pain like any muscles in different body sections. Ordinary factors like a bad sitting posture can cause the upper back and shoulder muscles to contract and strain. Studies reveal that the effects of bad sitting posture can lead to the development of a forwarding head posture with rounded shoulders, causing pain in the rhomboid muscles. When the shoulder muscles, like the rhomboid muscles, experience this sort of change over time, it can increase muscle tone and continuous stress in the neck and shoulders. To that point, it can lead to various symptoms like pain, numbness, loss of functionality in the upper limbs, and nerve root symptoms. Other issues like back pain can also be one of the symptoms that can lead to referred pain in the rhomboid muscles and can potentially lead to the development of trigger points along the shoulders and rhomboid muscles.
Other issues that can affect the rhomboid muscles are trigger points. Trigger points can be latent or active as they are tiny knots formed in the body’s muscle fibers. For the rhomboid muscles according to Dr. Janet G. Travell, M.D., when a person hears snapping and crunching noises during the movement of the shoulder blades, it may be due to the trigger points in the rhomboid muscles. Studies reveal that since trigger points can be either active or latent and elicit local referred pain, that can lead to muscle imbalance, weak and impaired motor function, and expose the joints to suboptimal loading. This means that trigger points in the rhomboid muscles can cause referred pain to the shoulder and mimic other chronic symptoms.
Stretching The Rhomboid Muscle & Managing Trigger Points-Video
Do you hear any snapping or crunching noises when rotating your shoulders? What about muscle stiffness along your shoulders or upper back? Or do you feel muscle aches from being hunched over for a long time? These symptoms could potentially involve trigger points associated with the rhomboid muscles. The rhomboid muscles help stabilize the shoulders and provide movement to the arms. When people overuse their shoulder muscles, it can cause the surrounding muscles to develop trigger points and inflict pain-like symptoms on the shoulders and upper back. Thankfully, all is not lost, as various treatments are available to relieve shoulder and upper back pain associated with trigger points along the rhomboid muscles. The video above explains where the trigger points are located on the rhomboid muscles and how to stretch that muscle to relieve trigger points from causing referred pain to the shoulders.
Managing Trigger Points Associated With The Rhomboid Muscle
Since the rhomboid muscles can become stiff due to overuse and could develop trigger points to inflict pain along the upper back and shoulders, this can cause many symptoms associated with pain and make the individual feel hopeless. Thankfully, various treatments can help manage trigger point pain associated with the rhomboid muscles. Studies reveal that thoracic spinal manipulation can relieve pain pressure sensitivity of the rhomboid muscles. Chiropractors are excellent when finding trigger points along the musculoskeletal system by utilizing spinal manipulation on the thoracic spine to loosen up the stiff muscles along the shoulders and upper back. Another way to manage trigger points associated with the rhomboid muscle is to stretch the shoulder muscles after a hot shower. This allows the muscles to relax and prevent future trigger points from forming along the rhomboid muscles.
The rhomboid muscles are a collective muscle group that has an important function in stabilizing the shoulder’s girdle and scapula (shoulder blades) while providing upper limb movement. The rhomboid muscles consist of two separate muscles: rhomboid minor and rhomboid major, which are behind the shoulder blades and deep within the trapezius muscles. When ordinary factors like poor posture or shoulder injuries affect the rhomboid muscles, it can develop trigger points that can cause stiffness in the rhomboid muscles. Various techniques can alleviate the referred pain along the shoulders, causing trigger points to develop along the rhomboid muscles. When these treatments are utilized on the rhomboid muscles, they can help prevent future shoulder issues.
Farrell, Connor, and John Kiel. “Anatomy, Back, Rhomboid Muscles.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 20 May 2022, www.ncbi.nlm.nih.gov/books/NBK534856/.
Haleema, Bibi, and Huma Riaz. “Effects of Thoracic Spine Manipulation on Pressure Pain Sensitivity of Rhomboid Muscle Active Trigger Points: A Randomized Controlled Trial.” JPMA. The Journal of the Pakistan Medical Association, U.S. National Library of Medicine, July 2021, pubmed.ncbi.nlm.nih.gov/34410234/.
Ribeiro, Daniel Cury, et al. “The Prevalence of Myofascial Trigger Points in Neck and Shoulder-Related Disorders: A Systematic Review of the Literature.” BMC Musculoskeletal Disorders, BioMed Central, 25 July 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6060458/.
Yoo, Won-Gyu. “Effects of Pulling Direction on Upper Trapezius and Rhomboid Muscle Activity.” Journal of Physical Therapy Science, The Society of Physical Therapy Science, June 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5468195/.
When many individuals look for ways to relax after a stressful event in their daily lives, many people have an exercise regime that allows them to take their minds off of their hectic lives. When finding the proper exercise, it is best to consider that everybody is different and has different fitness levels. Many individuals could be dealing with chronic issues that affect them drastically and with so much pain in their bodies. When these chronic issues overlap with muscle and joint pain, it can make the body dysfunctional while potentially being involved in environmental factors. Yoga is a low-impact exercise that helps tone muscles, relax tension in the body, and focus on deep breathing. Today’s article looks at the benefits of yoga for the body, how chiropractic care works together with yoga, and different yoga poses can help manage various chronic issues. We refer patients to certified providers specializing in musculoskeletal treatments to help many individuals with musculoskeletal problems affecting their bodies. We also guide our patients by referring to our associated medical providers based on their examination when it’s appropriate. We find that education is the solution to asking our providers insightful questions. Dr. Alex Jimenez DC provides this information as an educational service only. Disclaimer
Have you been dealing with chronic stress affecting your quality of life? Have you been dealing with bladder or gut issues constantly? What about feeling muscle stiffness in your back, neck, shoulders, or pelvic regions? Some of these symptoms are signs that you could risk developing musculoskeletal problems associated with pain. Dealing with musculoskeletal issues related to pain can make a person feel miserable and have stress affecting their bodies. Yoga is a low-impact exercise that doesn’t put pressure on the joints and will provide a full-body workout through strengthening and stretching weak muscles. Yoga has many benefits for many individuals that are dealing with the following:
Studies reveal that environmental factors are involved in non-specified chronic pain in the spine, overlapping musculoskeletal disorders causing many individuals to try to find relief. Many individuals incorporate yoga because it is a safe and effective way to alleviate various forms of back, neck, or pelvic pain causing issues to the body. Yoga utilizes gentle stretching and strengthening of weak, injured muscles while increasing blood circulation to promote healing in the body.
Chiropractic Care & Yoga
When people are dealing with health conditions or injuries that have affected their bodies, it can make them feel frustrated and think their injuries are taking forever to heal. Many individuals don’t realize that incorporating yoga practices provides impressive health benefits while mirroring the similar foundations of chiropractic care. Both chiropractic care and yoga provide many beneficial results to an aching body that needs a good stretch and ready the body to heal itself naturally. Chiropractic care includes spinal manipulation to the spinal joints while reducing inflammation and strengthening weak muscles. Yoga allows the body to increase its flexibility and stamina, reduces stress and blood pressure, and provides a better sense of breathing and balance.
Yoga For Chronic Pain-Video
Have you felt muscle stiffness in your neck, back, or body? Have you felt sluggish or overly stressed from your day-to-day lives? Do you want to improve your balance? If you have been experiencing these issues affecting your quality of life, why not incorporate yoga as part of your exercise regime? The video above shows that yoga poses for chronic pain affect the body, including the neck, back, and pelvic regions. Studies reveal that yoga can help relieve intense neck pain while improving pain-related function disability. Yoga allows the muscles to not only relax but strengthen them as well. Yoga can also help improve the body’s range of motion through deep breathing and give more awareness of how the body holds tension in places a person hasn’t realized they were holding onto.
Yoga Poses For Different Issues
When a person does yoga, they will go through various poses and repeat them constantly as their body begins to get used to the movements. This allows the body to challenge itself and helps the individual focus more on deep breathing. A good example would be an individual taking a yoga class due to experiencing pelvic pain. By going through each yoga pose, many individuals suffering from pelvic pain will reduce the pain intensity while improving their quality of life. Below are some yoga poses that anyone can do to reduce pain associated with their back, neck, or pelvis.
Lie on your back
Bend both knees while placing the feet on the floor at hip-width apart
Arm on the sides with palms facing down
Press feet to the floor and lift the hips as you inhale
Engage the legs and buttock
Hold 4-8 breaths and exhale to lower the hips back to the ground slowly
Lie on your stomach with hands near the chest just under the shoulders and fingers facing forward
Keep elbows close to sides
Press hands on the floor and slowly lift your head, chest, and shoulders while slightly bending the elbows by inhaling
Exhale to go back down slow and rest your head
Be on all fours, hands under the shoulders and knees under hips (Think like a table)
Inhale to lower your core to the floor as your head looks up to the sky
Exhale slowly to lower your chin to the chest as you round your back
Continue fluid motion for a minute
Be in a standing position, and feet are at a hip distance apart
Lengthen the body as you lean forward while keeping the knees slightly bended
Place hands on either legs, yoga block, or the floor (Whichever makes you comfortable)
Tuck the chin into the chest, letting the neck and head relax
Gently rock your head side to side to relieve tension in the neck and shoulders
Slowly roll up to a standing position allowing the arms and head to be the last to rise
Supine Spinal Twist
Lie on your back while your knees bent and feet flat on the floor
Extend arms out of the side and place palms down on the floor
As you inhale, breathe into the gut and lower limbs
Exhale to lower knees on the left side (Look at the opposite way to slowly stretch the neck and shoulder muscles)
Pay attention to the stretches for 5 breathes as well as the lengthening sensations on the ribs
Return the knees to the middle and repeat on the right side
Sit back on the heels with the knees together (For added support, you can use a rolled-up blanket under your knees)
Bend forward and walk hands in front of you
Gently rest your forehead on the floor
Keep arms extended in the front while focusing on relieving tension in the back as the upper body falls to the knees
Stay in that pose for 5 minutes
Incorporating yoga as part of an exercise regime allows the individual to focus on deep breathing while calming the mind. Yoga is a low-impact exercise that helps strengthen weak muscles associated with pain and inflammation. Yoga provides a full-body workout that benefits many people dealing with chronic pain. Utilizing yoga as part of a daily practice might help individuals learn to be calm and practice mindfulness.
Crow, Edith Meszaros, et al. “Effectiveness of Iyengar Yoga in Treating Spinal (Back and Neck) Pain: A Systematic Review.” International Journal of Yoga, Medknow Publications & Media Pvt Ltd, Jan. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4278133/.
Saxena, Rahul, et al. “Effects of Yogic Intervention on Pain Scores and Quality of Life in Females with Chronic Pelvic Pain.” International Journal of Yoga, Medknow Publications & Media Pvt Ltd, 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5225749/.
The digestive system in the body helps with the process of digesting food that the host consumes. The food being digested goes through a bio-transformation where it turns into nutrients and is stored in the intestines, liver, and gallbladder, where it turns into bile to be excreted out of the system to ensure a healthy functional gut system and body. But when disruptive factors like poor eating habits or gut issues start to affect the body and gallbladder, this causes many problems that can make an individual miserable. This affects their quality of life since they are dealing with painful issues in their bodies that overlap the primary source risk profiles. Today’s article looks at the gallbladder, how it functions with the body and parasympathetic nervous system, and how referred shoulder pain and gallbladder dysfunction are connected. We refer patients to certified providers specializing in gastroenterology and chiropractic treatments that help those with issues that affect their shoulders and gallbladder. We also guide our patients by referring to our associated medical providers based on their examination when it’s appropriate. We find that education is the solution to asking our providers insightful questions. Dr. Alex Jimenez DC provides this information as an educational service only. Disclaimer
The digestive system comprises the mouth, the internal organs from the GI tract, the liver, the gallbladder, and the anus, where food is consumed, digested, and excreted out of the body to keep it healthy. The gallbladder is a small organ that store and releases bile at the appropriate time into the intestines to be mixed with the digested foods to be excreted out of the body. This pear-shaped organ inflates and deflates like a balloon when it stores and releases bile while having a casual relationship with the nerves and hormones that help regulate the gallbladder functioning properly. Studies reveal that the ganglia become the target of causing the hormone cholecystokinin and the parasympathetic nerve to up or downregulate the neurotransmission to the gallbladder. This causes the gallbladder to be functional in the body.
What Are Its Functions In The Parasympathetic Nervous System?
So what are the functions that the gallbladder provides to the body? For starters, the parasympathetic nervous system allows the body to rest and digest the consumed food to be turned into nutrients. The parasympathetic nervous system also provides gallbladder stimulation as studies reveal that the gallbladder receives innervation from the parasympathetic nervous system connected to the vagus nerve that transmits information to the spine and the brain. Keeping and releasing bile from this pear-shaped organ helps regulate the gastrointestinal tract. This causal relationship between the gallbladder and the parasympathetic nerve is essential because the body needs to know when to store and release bile from the gallbladder, or it might trigger some issues that can do more harm to the body and even affect the gallbladder itself.
Do You Have Shoulder Pain?- Video
Have you been experiencing gut issues causing a sharp or dull ache in your back or sides? How about questionable shoulder pain that seems to come out of nowhere? Or are your experiencing inflammation in your digestive system? Many of these symptoms are signs of visceral-somatic pain affecting the gallbladder. Visceral-somatic pain is defined when there is damage to the organ, and it starts to affect the muscles in a different location in the body. The video above gives an excellent example of visceral-somatic pain in the gallbladder and the shoulder. Now many people wonder how shoulder pain is the mediator of the gallbladder? Well, inflammation in the liver and gallbladder causes the nerve roots to be hypersensitive and compressed. This leads to overlapping profiles, triggering pain in the shoulder muscles and associated with upper mid-back pain.
Referred Shoulder Pain & Gallbladder Dysfunction
Now say the individual is experiencing shoulder pain; however, when they rotate their shoulder, there is no pain? Where is the source of shoulder pain localized, and what is causing the issue? And why is it correlating to the gallbladder? This is known as referred pain, where the source of pain is poorly localized when it is located elsewhere. Studies reveal that gallbladder dysfunctions like cholecystitis might be associated with acute thoracolumbar shoulder pain. So what does this mean? It means that any referred pain that is the causation of shoulder pain gives the impression that something is wrong with the gallbladder. This would provide much-needed information when individuals are being examined by their physicians.
The body needs the digestive system to help process food the host consumes and excretes for a healthy functioning system. The gallbladder stores and releases bile to the digested food. This ensures that the nutrients and bile are transported and passed out of the body. When disruptive factors cause gut issues and affect the gallbladder, it can correlate to different problems impacting the body. An example would be gallbladder issues associated with shoulder pain. This is referred to as pain, which is from an affected organ and associated with the muscle in a different location. This can make the individual feel miserable and wonder what is going on with their shoulders when it might be something associated with their gallbladder. Available treatments can provide better knowledge to determine the problem and how to alleviate the issues.
The spine has three areas: cervical, thoracic, and lumbar in the back, encased with muscles, tissues, ligaments, and joints that help protect the spinal cord from injuries. With the spinal cord being part of the central nervous system, this long cord has many nerve roots that are spread all over the body and help function each section of the body. When the back muscles become damaged or injured in the thoracic region of the spine, it can cause painful symptoms and other issues that correspond with the thoracic spine. Today’s article will look at the thoracic spine, how back pain in the upper-mid section of the back, and how visceral referred pain affects the thoracic region in the body. We refer patients to certified, skilled providers specializing in osteopathic and chiropractic treatments that help those suffering from chest pains and thoracic back pain. We also guide our patients by referring to our associated medical providers based on their examination when it’s appropriate. We find that education is critical for asking insightful questions to our providers. Dr. Alex Jimenez DC provides this information as an educational service only. Disclaimer
Can my insurance cover it? Yes, it may. If you are uncertain, here is the link to all the insurance providers we cover. If you have any questions or concerns, please call Dr. Jimenez at 915-850-0900.
Have you been experiencing herniation in the upper-mid section of your back? Have you felt chest pain occur frequently? Do your back muscles feel stiff or constantly ache even after you stretch? All these symptoms are signs that affect the thoracic region of the spine. Research studies have defined the three spinal areas: the cervical, thoracic, and lumbar help keep the upper half of the body upright. The thoracic area of the spine has added support from the rib cage and allows the body to rotate and flex the upper body. The thoracic region of the spine is also the first curvature that is tight enough to protect the vital organs and loose enough to allow respiratory movement in the body. Additional research studies have also mentioned that the thoracic segments in the spine are susceptible to injuries that can affect the back entirely. The thoracic segments can succumb to structural alterations, disc herniation, and even trauma in the spine from environmental factors like lifting or carrying heavy objects, muscle strain, and forceful impact.
How Thoracic Pain Affect The Body
When the thoracic region of the spine begins to suffer from environmental factors or traumatic events, it can affect the body and aggravate the nerves that encase the spinal column. Research studies have found that when the thoracic spine has succumbed to injuries, it can affect the upper half of the body. Structural changes in the thoracic T 1 through 3 regions of the spine can cause the cervical area to develop neck pain. This causes restricted segmental mobility in the cervical and thoracic regions of the spine. Another research study has mentioned that individuals suffering from thoracic pain will often complain about paravertebral pain aggravated by prolonged standing, hyperextension, and even hyper rotation in the thoracic spinal column. When this happens, it can cause discomfort to the individual and limit their range of motion since their muscles are stiff. Thoracic pain can even affect the corresponding muscles connected to the body’s internal organs.
Referred Pain Affect The Thoracic Spine-Video
Have you felt muscle stiffness in your upper-middle back? Have you been dealing with neck or chest pain? Have inflammatory issues affecting your esophagus? Many of these are signs and symptoms of visceral referred pain affecting the thoracic region of the spine. The video above explains how visceral referred pain can affect the thoracic spine and the corresponding muscle and organs in the area. Research studies have defined pain as damaged nociceptive sensory nerves that affect the peripheral tissues in the face. The broken nerve roots can affect one portion of the body but also a different section of the body. Additional research studies have also found that visceral pain affecting the thoracic regions of the spine can impact the cardiovascular system. This is due to hypertension caused by chronic stress from environmental factors.
Visceral Referred Pain Affecting The Thoracic Region
Research studies have noticed that thoracic spinal pain can become a common site for inflammation, degenerative discs, and other issues contributing to pain and disability in the spine. Visceral pain is a complex disorder that can cause the surrounding muscles and organs in the thoracic region to be compromised. When the body is suffering from visceral referred pain, the thoracic region of the spine will also begin to suffer. Additional research studies have found that visceral referred pain that affects the thoracic neurons will also affect the esophageal and cardiac input to the cardiovascular and gut systems. When the affected thoracic neurons begin to cause heart and esophageal problems, these two organs become hypersensitive due to noxious stimulation.
The spine has three areas: the cervical, thoracic, and lumbar, which help keep the body upright and is encased with muscles, tissues, and ligaments that protect the spinal cord from injuries. Injuries that affect the thoracic regions of the back can cause problems to the corresponding muscles and the internal organs, especially in the gut and cardiovascular systems. These organs become hyper-sensitive and can make the body develop hypertension and other issues that can make the body dysfunctional. When individuals realize that their upper-middle back pain in the thoracic region can affect their cardiovascular system, they can find ways to treat their back pain and prevent cardiovascular issues from forming.
Briggs, Andrew M, et al. “Thoracic Spine Pain in the General Population: Prevalence, Incidence and Associated Factors in Children, Adolescents and Adults. A Systematic Review.” BMC Musculoskeletal Disorders, BioMed Central, 29 June 2009, www.ncbi.nlm.nih.gov/pmc/articles/PMC2720379/.
Brumovsky, P R, and G F Gebhart. “Visceral Organ Cross-Sensitization – an Integrated Perspective.” Autonomic Neuroscience: Basic & Clinical, U.S. National Library of Medicine, 16 Feb. 2010, www.ncbi.nlm.nih.gov/pmc/articles/PMC2818077/.
Gkasdaris, Grigorios, et al. “Clinical Anatomy and Significance of the Thoracic Intervertebral Foramen: A Cadaveric Study and Review of the Literature.” Journal of Craniovertebral Junction & Spine, Medknow Publications & Media Pvt Ltd, 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5111324/.
Joshi, Shriya, et al. “Thoracic Posture and Mobility in Mechanical Neck Pain Population: A Review of the Literature.” Asian Spine Journal, Korean Society of Spine Surgery, 3 June 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6773982/.
Everybody is always moving in their vehicles as they go from one place to another in less time. Sometimes accidents happen as vehicles collide with each other and cause excruciating pain to the body as it lunges forward, causing back and neck pain to the individual. These are physical effects on the body, but the emotional impact also takes a toll on the individual. It can cause a person to become miserable and affect their quality of life. Today’s article discusses the effects of an auto accident are cause the back and body, as well as how non-surgical decompression therapy can help alleviate the pain in the back from an auto accident. Patients are referred to qualified, skilled providers specializing in spinal decompression and non-surgical treatments. We go hand in hand with our patients by referring them to our associated medical providers based on their examination when it’s appropriate. We find that education is valuable for asking critical questions to our providers. Dr. Jimenez DC provides this information as an educational service only. Disclaimer
Can my insurance cover it? Yes, it may. If you are uncertain, here is the link to all the insurance providers we cover. If you have any questions or concerns, please call Dr. Jimenez at 915-850-0900.
Have you suffered from back pain after a vehicle collision? What about experiencing whiplash or neck pain? Or has your lower back been feeling stiff and aches more? Many of these symptoms are signs that the spine, back, and neck all have suffered from the effects of an auto accident. Research has shown that the impact of a person in an auto accident causes the body to rapidly lunge forward and back after a complete stop, causing damage to the body, especially on the spine. After the auto accident has occurred, many individuals don’t feel the effects of the injuries that are caused by auto accidents sometimes until the day after the accident. This is due to the adrenaline in the body, which is both a neurotransmitter and a hormone and is fully turned on to the max. Additional information has stated that many individuals suffer from low back pain after a motor vehicle collision. Even if the accident was non-lethal, the impact can cause strain on the lower back muscles and compress the spinal nerves, making them irritated.
How The Body Is Affected
Research studies have shown that the impact of an auto accident may cause the body to have non-fatal physical injuries but also cause psychological trauma that can affect a person’s psyche. Many people that have experienced an auto accident will have various emotions that leave them in shock. During that process, emotions like distress, helplessness, anger, shock, and frustration are presented as the individual who was in the accident experience these negative emotions. Additional research also found that many individuals can experience low back pain episodes reoccurring along with the emotional presence that they are feeling. Fortunately, there are ways to alleviate low back pain caused by auto accidents and can help restore the spine to its functionality.
Spinal Decompression Therapy Alleviates Auto Accident Injuries- Video
Have you experienced low back pain after a car accident? How about feeling the effects of muscle stiffness on the neck and low back the day after? Do emotions like stress, frustration, and shock affect your quality of life? These are signs and symptoms of what a person is going through after being involved in an auto accident and dealing with neck and back pain. There are ways to treat neck and back pain through decompression, and the video above explains the impressive effects of what decompression does to the individual. Decompression is a non-surgical treatment that allows gentle traction to alleviate the flattened spinal disc and take the pressure off the aggravated nerves surrounding the spine. The gentle traction also pumps the nutrients back to the dehydrated discs while increasing their heights. This link will explain what decompression offers and the impressive results for many individuals who suffer from back or neck pain due to an auto accident.
How Spinal Decompression Helps Relieve The Spine After Auto Accidents
After a person suffers from an auto accident, they experience pain in their spine and back the day before or after. Many individuals who suffer from low back pain, neck pain, and whiplash from auto accidents tend to find ways to alleviate the pain in their spine. One of these treatments is spinal decompression. Spinal decompression allows the individual to sit on a traction table in a supine position and be strapped in. Research studies have mentioned that spinal decompression is a non-surgical treatment for many individuals suffering from low back pain. In contrast, the traction machine slowly but gently pulls the spine to relieve the pain caused by a spinal injury due to an accident. This will provide effective recovery for many individuals suffering from low back pain. Additional information also mentioned that the effectiveness of decompression could reduce the inflammatory markers induced by the aggravated nerve roots through negative pressure, thus causing relief to the back.
Overall, suffering low back pain or neck pain after an auto accident is nerve-wracking for many individuals. The emotional and physical trauma caused by a motor vehicle collision can dampen a person’s mood, and the residual pain afterward can affect their quality of life. Utilizing decompression for non-surgical treatments can provide beneficial results in restoring functionality back in the spine and alleviating the pain the person is in. When people use decompression, they can get back to their activities and become pain-free from their lower back.
Daniel, Dwain M. “Non-Surgical Spinal Decompression Therapy: Does the Scientific Literature Support Efficacy Claims Made in the Advertising Media?” Chiropractic & Osteopathy, BioMed Central, 18 May 2007, www.ncbi.nlm.nih.gov/pmc/articles/PMC1887522/.
Kang, Jeong-Il, et al. “Effect of Spinal Decompression on the Lumbar Muscle Activity and Disk Height in Patients with Herniated Intervertebral Disk.” Journal of Physical Therapy Science, The Society of Physical Therapy Science, Nov. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5140813/.
Nolet, Paul S, et al. “Exposure to a Motor Vehicle Collision and the Risk of Future Back Pain: A Systematic Review and Meta-Analysis.” Accident; Analysis and Prevention, U.S. National Library of Medicine, July 2020, pubmed.ncbi.nlm.nih.gov/32438092/.
Nolet, Paul S, et al. “The Association between a Lifetime History of Low Back Injury in a Motor Vehicle Collision and Future Low Back Pain: A Population-Based Cohort Study.” European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, U.S. National Library of Medicine, Jan. 2018, pubmed.ncbi.nlm.nih.gov/28391385/.
The lower half of the body consists of the low back, hips, legs, and feet to stabilize the upper body. The motor-sensory function helps the lower portion of the body move the leg muscles and sense when the lower back muscles are in pain. The lower back muscles help twist and turn the upper body without feeling discomfort or pain when it is in motion. Many ordinary factors put the lower back muscles to the test, which can become a nuisance later on if not treated right away. Factors like lifting and carrying heavy objects, being hunched over, and injuries can affect the lower back while causing immense pain to the lumbar spine. When injuries occur in the lower back, unwanted symptoms start to take effect, causing the individual to suffer and find some relief to alleviate the pain. Today’s article will focus on what causes lumbar stenosis, how it is associated with low back pain, and how traction therapy can help alleviate lumbar stenosis for many people. Patients are referred to qualified, skilled providers who specialize in spinal decompression and traction therapy. We go hand in hand with our patients by referring them to our associated medical providers based on their examination when it’s appropriate. We find that education is valuable for asking critical questions to our providers. Dr. Jimenez DC provides this information as an educational service only. Disclaimer
Can my insurance cover it? Yes, it may. If you are uncertain, here is the link to all the insurance providers we cover. If you have any questions or concerns, please call Dr. Jimenez at 915-850-0900.
Experiencing mild to chronic pain in your lower back? Do you feel unstable when walking or running to your destination? Or have you experienced symptoms of muscle weakness or tenderness around your lower back? Many of these symptoms are caused by lumbar spinal stenosis. Research studies have defined lumbar stenosis as intervertebral spinal discs in the lumbar regions starting to degenerate naturally, causing the lower extremities to become hypermobile around the facet joints. When this happens to the spinal joint over time, it causes a reduction in the spinal canal, making the nerve roots that surround the spine irritated. Lumbar stenosis will gradually worsen as the pain symptoms range from mild to severe. Other research studies have shown that lumbar stenosis is caused due to natural aging in the spine that causes the degeneration process, thus leading to pain symptoms associated with stenosis.
How Low Back Pain Is Associated With Stenosis?
Research studies have found that lumbar stenosis is associated with leg and back pain when a person has lumbar stenosis, a common source in the lower back. Other back issues and symptoms are also playing an effect on the development of lumbar stenosis. Degenerative spondylosis causes an increased load on the posterior portions of the spine where the hips are located at. Additional research studies have shown that many suffering individuals will exhibit various symptoms associated with lumbar stenosis. Some of the signs that lumbar spinal stenosis does include:
Radiating pain in the lower limbs (buttock, legs, and feet)
Decrease sensory functions
Severe pain in posture stance
Increase chances of falling down
An Overview On Lumbar Traction-Video
Feeling radiating pain in your lower limbs? Do you feel muscle stiffness or tenderness in certain parts of your lower back? Have you experienced severe pain from standing or sitting for too long? Having lumbar spinal stenosis is no laughing matter for your lower back. The pain can become excruciating if it isn’t being taken care of, and that is where lumbar traction can help. The video above explains why lumbar traction is terrific when dealing with low back pain and lumbar stenosis. Lumbar traction helps loosen the tense muscles and resets the spinal discs that aggravate the nerve roots. Lumbar traction also provides relief to individuals suffering from sciatic nerve pain and can help rehydrate the dry intervertebral discs in the body. This link will explain what lumbar traction therapy offers and the impressive results for many individuals who suffer from lumbar spinal stenosis or other low back pain issues
How Traction Therapy Helps Alleviate Lumbar Stenosis
Many individuals looking for treatments that can help alleviate lumbar stenosis and low back can try lumbar traction therapy. Research studies have shown that traction therapy can help many suffering patients dealing with low back pain or lumbar stenosis will have a decrease in radicular pain in their lower back and legs. Lumbar traction helps relieve the surrounding nerves’ aggravated pressure, and radiculopathy symptoms are decreased in the lower back. Other research studies have mentioned that lumbar traction can help widen the spinal disc space in the spine while reducing low back pain and causing the sensory-motor functions to return to the legs. Lumbar traction therapy has many beneficial results for lower back pain relief for individuals.
Living with low back pain or lumbar stenosis is not a laughing matter for a person’s health. Overall, experiencing low back pain is no joke when associated with other symptoms like lumbar spinal stenosis. Lumbar stenosis causes the spinal canal to become narrow, and it can press on the surrounding nerve roots in the lumbar region. Many individuals who suffer from lumbar stenosis will have a wide range of pain in their lower extremities while feeling unstable when they are moving. When this happens, therapies like lumbar traction can help decompress the affected nerve roots and help widen the spinal canal and discs back to their original state. Incorporating traction and decompression therapy to alleviate low back pain can do many wonders for the individual.
Harte, Annette A, et al. “The Effectiveness of Motorised Lumbar Traction in the Management of LBP with Lumbo Sacral Nerve Root Involvement: A Feasibility Study.” BMC Musculoskeletal Disorders, BioMed Central, 29 Nov. 2007, www.ncbi.nlm.nih.gov/pmc/articles/PMC2217540/.
Disc bulge and disc herniation are some of the most common conditions affecting the spine of both young and middle-aged patients. It is estimated that approximately 2.6% of the US population annually visits a clinician to treat spinal disorders. Roughly $ 7.1 billion alone is lost due to the time away from work.
Disc herniation is when the whole or part of the nucleus pulposus is protruded through the torn or weakened outer annulus fibrosus of the intervertebral disc. This is also known as the slipped disc and frequently occurs in the lower back, sometimes also affecting the cervical region. Herniation of the intervertebral disc is defined as a localized displacement of disc material with 25% or less of the disc circumference on an MRI scan, according to the North American Spine Society 2014. The herniation may consist of nucleus pulposus, annulus fibrosus, apophyseal bone or osteophytes, and the vertebral endplate cartilage in contrast to disc bulge.
There are also mainly two types of disc herniation. Disc protrusion is when a focal or symmetrical extension of the disc comes out of its confines in the intervertebral space. It is situated at the intervertebral disc level, and its outer annular fibers are intact. A disc extrusion is when the intervertebral disc extends above or below the adjacent vertebrae or endplates with a complete annular tear. In this type of disc extrusion, a neck or base is narrower than the dome or the herniation.
A disc bulge is when the outer fibers of the annulus fibrosus are displaced from the margins of the adjacent vertebral bodies. Here, the displacement is more than 25% of the circumference of the intervertebral disc. It also does not extend below or above the margins of the disc because the annulus fibrosus attachment limits it. It differs from disc herniation because it involves less than 25% of the disc’s circumference. Usually, the disc bulge is a gradual process and is broad. The disc bulge can be divided into two types. In a circumferential bulge, the whole disc circumference is involved. More than 90 degrees of the rim is involved asymmetrically in asymmetrical bulging.
Normal Intervertebral Disc Anatomy
Before going into detail about the definition of disc herniation and disc bulge, we need to look at the standard intervertebral disc. According to spine guidelines in 2014, a standard disc is something that has a classic shape without any evidence of degenerative disc changes. Intervertebral discs are responsible for one-third to one-fourth of the height of the spinal column.
One intervertebral disc is about 7 -10 mm thick and measures 4 cm in anterior-posterior diameter in the lumbar region of the spine. These spinal discs are located between two adjacent vertebral bodies. However, no discs can be found between the atlas and axis and the coccyx. About 23 discs are found in the spine, with six in the cervical spine, 12 in the thoracic spine, and only five in the lumbar spine.
Intervertebral discs are made of fibro cartilages, forming a fibrocartilaginous joint. The outer ring of the intervertebral disc is known as the annulus fibrosus, while the inner gel-like structure in the center is known as the nucleus pulposus. The cartilage endplates sandwich the nucleus pulposus superiorly and inferiorly. The annulus fibrosus comprises concentric collagen fiber sheets arranged in a radial tire-like structure into lamellae. The fibers are attached to the vertebral endplates and oriented at different angles. With their cartilaginous part, the endplates anchor the discs in their proper place.
The nucleus pulposus is composed of water, collagen, and proteoglycans. Proteoglycans attract and retain moisture, giving the nucleus pulposus a hydrated gel-like consistency. Interestingly, throughout the day, the amount of water found in the nucleus pulposus varies according to the person’s level of activity. This feature in the intervertebral disc serves as a cushion or a spinal shock-absorbing system to protect the adjacent vertebra, spinal nerves, spinal cord, brain, and other structures against various forces. Although the individual movement of the intervertebral discs is limited, some form of vertebral motion like flexion and extension is still possible due to the features of the intervertebral disc.
Effect of Intervertebral Disc Morphology on Structure and Function
The type of components present in the intervertebral disc and how it is arranged determine the morphology of the intervertebral disc. This is important in how effectively the disc does its function. As the disc is the most important element which bears the load and allows movement in the otherwise rigid spine, the constituents it is made up of have a significant bearing.
The complexity of the lamellae increases with advancing age as a result of the synthetic response of the intervertebral disc cells to the variations in the mechanical load. These changes in lamellae with more bifurcations, interdigitation and irregular size and number of lamellar bands will lead to the altered bearing of weight. This in turn establishes a self-perpetuated disruption cycle leading to the destruction of the intervertebral discs. Once this process is started it is irreversible. As there is an increased number of cells, the amount of nutrition the disc requires is also increasingly changing the normal concentration gradient of both metabolites and nutrients. Due to this increased demand, the cells may also die increasingly by necrosis or apoptosis.
Human intervertebral discs are avascular and hence the nutrients are diffused from the nearby blood vessels in the margin of the disc. The main nutrients; oxygen and glucose reach the cells in the disc through diffusion according to the gradient determined by the rate of transport to the cells through the tissues and the rate of demand. Cells also increasingly produce lactic acid as a metabolic end product. This is also removed via the capillaries and venules back to the circulation.
Since diffusion depends on the distance, the cells lying far from the blood capillaries can have a reduced concentration of nutrients because of the reduced supply. With disease processes, the normally avascular intervertebral disc can become vascular and innervated in degeneration and in disease processes. Although this may increase the oxygen and nutrient supply to the cells in the disc, this can also give rise to many other types of cells that are normally not found in the disc with the introduction of cytokines and growth factors.
The morphology of the intervertebral disc in different parts of the spine also varies although many clinicians base the clinical theories based on the assumption that both cervical and lumbar intervertebral discs have the same structure. The height of the disc was the minimum in the T4-5 level of the thoracic column probably due to the fact that thoracic intervertebral discs are less wedge-shaped than those of cervical and lumbar spinal regions.
From the cranial to caudal direction, the cross-sectional area of the spine increased. Therefore, by the L5-S1 level, the nucleus pulposus was occupying a higher proportion of the intervertebral disc area. The cervical discs have an elliptical shape on cross-section while the thoracic discs had a more circular shape. The lumbar discs also have an elliptical shape though it is more flattened or re-entrant posteriorly.
What is a Disc Bulge?
The bulging disc is when the disc simply bulges outside the intervertebral disc space it normally occupies without the rupture of the outer annulus fibrosus. The bulging area is quite large when compared to a herniated disc. Moreover, in a herniated disc, the annulus fibrosus ruptures or cracks. Although disc bulging is more common than disc herniation, it causes little or no pain to the patient. In contrast, the herniated disc causes a lot of pain.
Causes for Disc Bulging
A bulging disc can be due to several causes. It can occur due to normal age-related changes such as those seen in degenerative disc disease. The aging process can lead to structural and biochemical changes in the intervertebral discs and lead to reduced water content in the nucleus pulposus. These changes can make the patient vulnerable to disc bulges with only minor trauma. Some unhealthy lifestyle habits such as a sedentary lifestyle and smoking can potentiate this process and give rise to more severe changes with the weakening of the disc.
General wear and tear due to repeated microtrauma can also weaken the disc and give rise to disc bulging. This is because when the discs are strained, the normal distribution of weight loading changes. Accumulated micro-trauma over a long period of time can occur in bad posture. Bad posture when sitting, standing, sleeping, and working can increase the pressure in the intervertebral discs.
When a person maintains a forward bending posture, it can lead to overstretching and eventually weakness of the posterior part of the annulus fibrosus. Over time, the intervertebral disc can bulge posteriorly. In occupations that require frequent and repetitive lifting, standing, driving, or bending, the bulging disc may be an occupational hazard. Improper lifting up of items, and improper carrying of heavy objects can also increase the pressure on the spine and lead to disc bulges eventually.
The bulging intervertebral discs usually occur over a long period of time. However, the discs can bulge due to acute trauma too. The unexpected sudden mechanical load can damage the disc resulting in micro-tears. After an accident, the disc can become weakened causing long-term microdamage ultimately leading to bulging of the disc. There may also be a genetic component to the disc bulging. The individual may have a reduced density of elastin in the annulus fibrosus with increased susceptibility to disc diseases. Other environmental facts may also play a part in this disease process.
Symptoms of Disc Bulging
As mentioned previously, bulging discs do not cause pain and even if they do the severity is mild. In the cervical region, the disease will cause pain running down the neck, deep pain in the shoulder region, pain radiating along the upper arm, and forearm up to the fingers.
This may give rise to a diagnostic dilemma as to whether the patient is suffering from a myocardial infarction as the site of referred pain and the radiation is similar. Tingling feeling on the neck may also occur due to the bulging disc.
In the thoracic region, there may be pain in the upper back that radiates to the chest or the upper abdominal region. This may also suggest upper gastrointestinal, lung, or cardiac pathology and hence need to be careful when analyzing these symptoms.
The bulging discs of the lumbar region may present as lower back pain and tingling feeling in the lower back region of the spine. This is the most common site for disc bulges since this area holds the weight of the upper body. The pain or the discomfort can spread through the gluteal area, thighs, and to the feet. There may also be muscle weakness, numbness or tingling sensation. When the disc presses on the spinal cord, the reflexes of both legs can increase leading to spasticity.
Some patients may even have paralysis from the waist down. When the bulging disc compresses on the cauda equine, the bladder and bowel functions can also change. The bulging disc can press on the sciatic nerve leading to sciatica where the pain radiates in one leg from the back down to the feet.
The pain from the bulging disc can get worse during some activities as the bulge can then compress on some of the nerves. Depending on what nerve is affected, the clinical features can also vary.
Diagnosis of Disc Bulging
The diagnosis may not be apparent from clinical history due to similar presentations in more serious problems. But the chronic nature of the disease may give some clues. Complete history and a physical examination need to be done to rule out myocardial infarction, gastritis, gastro-oesophageal reflux disease, and chronic lung pathology.
MRI of Disc Bulge
Investigations are necessary for the diagnosis. X-ray spine is performed to look for gross pathology although it may not show the bulging disc directly. There may be indirect findings of disk degeneration such as osteophytes in the endplates, gas in the disc due to the vacuum phenomenon, and the loss of height of the intervertebral disc. In the case of moderate bulges, it may sometimes appear as non-focal intervertebral disc material that is protruded beyond the borders of the vertebra which is broad-based, circumferential, and symmetrical.
Magnetic resonance imaging or MRI can exquisitely define the anatomy of the intervertebral discs especially the nucleus pulposus and its relationships. The early findings seen on MRI in disc bulging include the loss of normal concavity of the posterior disc. The bulges can be seen as broad-based, circumferential, and symmetrical areas. In moderate bulging, the disc material will protrude beyond the borders of the vertebrae in a non-focal manner. Ct myelogram may also give detailed disc anatomy and may be useful in the diagnosis.
Treatment of Disc Bulging
The treatment for the bulging disc can be conservative, but sometimes surgery is required.
When the disc bulging is asymptomatic, the patient does not need any treatment since it does not pose an increased risk. However, if the patient is symptomatic, the management can be directed at relieving the symptoms. The pain is usually resolved with time. Till then, potent pain killers such as non-steroidal anti-inflammatory drugs like ibuprofen should be prescribed. In unresolved pain, steroid injections can also be given to the affected area and if it still does not work, the lumbar sympathetic block can be tried in most severe cases.
The patient can also be given the option of choosing alternative therapies such as professional massage, physical therapy, ice packs, and heating pads which may alleviate symptoms. Maintaining correct posture, tapes, or braces to support the spine are used with the aid of a physiotherapist. This may fasten the recovery process by avoiding further damage and keeping the damaged or torn fibers in the intervertebral disc without leakage of the fluid portion of the disc. This helps maintain the normal structure of the annulus and may increase the recovery rate. Usually, the painful symptoms which present initially get resolved over time and lead to no pain. However, if the symptoms get worse steadily, the patient may need surgery
If the symptoms are resolved, physiotherapy can be used to strengthen the muscles of the back with the use of exercises. Gradual exercises can be used for the return of function and for preventing recurrences.
When conservative therapy does not work with a few months of treatment, surgical treatment can be considered. Most would prefer minimally invasive surgery which uses advanced technology to correct the intervertebral disc without having to grossly dissect the back. These procedures such as microdiscectomy have a lower recovery period and reduced risk of scar formation, major blood loss, and trauma to adjacent structures when compared to open surgery.
Previously, laminectomy and discectomy have been a mainstay of treatment. However, due to the invasiveness of the procedure and due to increased damage to the nerves these procedures are currently abandoned by many clinicians for disc bulging.
Disc bulging in the thoracic spine is being treated surgically with costotransversectomy where a section of the transverse process is resected to allow access to the intervertebral disc. The spinal cord and spinal nerves are decompressed by using thoracic decompression by removing a part of the vertebral body and making a small opening. The patient may also need a spinal fusion later on if the removed spinal body was significant.
Video-assisted thoracoscopic surgery can also be used where only a small incision is made and the surgeon can perform the surgery with the assistance of the camera. If the surgical procedure involved removing a large portion of the spinal bone and disc material, it may lead to spinal instability. This may need bone grafting to replace the lost portion with plates and screws to hold them in place.
What is a Disc Herniation?
As mentioned in the first section of this article, disc herniation occurs when there is disc material displaces beyond the limits of the intervertebral disc focally. The disc space consists of endplates of the vertebral bodies superiorly and inferiorly while the outer edges of the vertebral apophyses consist of the peripheral margin. The osteophytes are not considered a disc margin. There may be irritation or compression of the nerve roots and dural sac due to the volume of the herniated material leading to pain. When this occurs in the lumbar region, this is classically known as sciatica. This condition has been mentioned since ancient times although a connection between disc herniation and sciatica was made only in the 20th century. Disc herniation is one of the commonest diagnoses seen in the spine due to degenerative changes and is the commonest cause of spinal surgery.
Classifications of Disc Herniation
There are many classifications regarding intervertebral disc herniation. In focal disc herniation, there is a localized displacement of the disc material in the horizontal or axial plane. In this type, only less than 25% of the circumference of the disc is involved. In broad-based disc herniation, about 25 – 50 % of the disc circumference is herniated. The disc bulge is when 50 – 100 % of the disc material is extended beyond the normal confines of the intervertebral space. This is not considered a form of disc herniation. Furthermore, the intervertebral disc deformities associated with severe cases of scoliosis and spondylolisthesis are not classified as a herniation but rather adaptive changes of the contour of the disc due to the adjacent deformity.
Depending on the contour of the displaced material, the herniated discs can be further classified as protrusions and extrusions. In disc protrusion, the distance measured in any plane involving the edges of the disc material beyond intervertebral disc space (the highest measure is taken) is lower than the distance measured in the same plane between the edges of the base.
Imaging can show the disc displacement as a protrusion on the horizontal section and as an extrusion on the sagittal section due to the fact that the posterior longitudinal ligament contains the disc material that is displaced posteriorly. Then the herniation should be considered an extrusion. Sometimes the intervertebral disc herniation can occur in the craniocaudal or vertical direction through a defect in the vertebral body endplates. This type of herniation is known as intravertebral herniation.
The disc protrusion can also be divided into two focal protrusion and broad-based protrusion. In focal protrusion, the herniation is less than 25% of the circumference of the disc whereas, in broad-based protrusion, the herniated disc consists of 25 – 50 % of the circumference of the disc.
In disc extrusion, it is diagnosed if any of the two following criteria are satisfied. The first one is; that the distance measured between the edges of the disc material that is beyond the intervertebral disc space is greater than the distance measured in the same plane between the edges of the base. The second one is; that the material in the intervertebral disc space and material beyond the intervertebral disc space is having a lack continuity.
This can be further characterized as sequestrated which is a subtype of the extruded disc. It is called disc migration when disk material is pushed away from the site of extrusion without considering whether there is continuity of disc or not. This term is useful in interpreting imaging modalities as it is often difficult to show continuity in imaging.
The intervertebral disc herniation can be further classified as contained discs and discs that are unconfined. The term contained disc is used to refer to the integrity of the peripheral annulus fibrosus which is covering the intervertebral disc herniation. When fluid is injected into the intervertebral disc, the fluid does not leak into the vertebral canal in herniations that are contained.
Sometimes there are displaced disc fragments that are characterized as free. However, there should be no continuity between disc material and the fragment and the original intervertebral disc for it to be called a free fragment or a sequestered one. In a migrated disc and in a migrated fragment, there is an extrusion of disc material through the opening in the annulus fibrosus with a displacement of the disc material away from the annulus.
Even though some fragments that are migrated can be sequestered the term migrated means just to the position and it is not referred to the continuity of the disc. The displaced intervertebral disc material can be further described with regard to the posterior longitudinal ligament as submembranous, subcapsular, subligamentous, extra ligamentous, transligamentous, subcapsular, and perforated.
The spinal canal can also get affected by an intervertebral disc herniation. This compromise of the canal can also be classified as mild, moderate, and severe depending on the area that is compromised. If the canal at that section is compromised only less than one third, it is called mild whereas if it is only compromised less than two-thirds and more than one third it is considered moderate. In a severe compromise, more than two-thirds of the spinal canal is affected. For the foraminal involvement, this same grading system can be applied.
The displaced material can be named according to the position that they are in the axial plane from the center to the right lateral region. They are termed as central, right central, right subarticular, right foraminal, and right extraforaminal. The displaced intervertebral disc material’s composition can be further classified as gaseous, liquefied, desiccated, scarred, calcified, ossified, bony, nuclear, and cartilaginous.
Before going into detail on how to diagnose and treat intervertebral disc herniation, let us differentiate how cervical disc herniation differs from lumbar herniation since they are the most common regions to undergo herniation.
Cervical Disc Herniation vs. Thoracic Disc Herniation vs Lumbar Disc Herniation
Lumbar disc herniation is the most commonest type of herniation found in the spine which is approximately 90% of the total. However, cervical disc herniation can also occur in about one-tenth of patients. This difference is mainly due to the fact that the lumbar spine has more pressure due to the increased load. Moreover, it has comparatively large intervertebral disc material. The most common sites of intervertebral disc herniation in the lumbar region are L 5 – 6, in the Cervical region between C7, and in the thoracic region T12.
Cervical disc herniation can occur relatively commonly because the cervical spine acts as a pivoting point for the head and it is a vulnerable area for trauma and therefore prone to damage in the disc. Thoracic disc herniation occurs more infrequently than any of the two. This is due to the fact that thoracic vertebrae are attached to the ribs and the thoracic cage which limits the range of movement in the thoracic spine when compared to the cervical and lumbar spinal discs. However, thoracic intervertebral disc herniation can still occur.
Cervical disc herniation gives rise to neck pain, shoulder pain, pain radiating from the neck to the arm, tingling, etc. Lumbar disc herniation can similarly cause lower back pain as well as pain, tingling, numbness, and muscle weakness seen in the lower limbs. Thoracic disc herniation can give rise to pain in the upper back radiating to the torso.
Although disc herniation can occur in all age groups, it predominantly occurs between the fourth and fifth decade of life with the mean age of 37 years. There have been reports that estimate the prevalence of intervertebral disc herniation to be 2 – 3 % of the general population. It is more commonly seen in men over 35 years with a prevalence of 4.8% and while in women this figure is around 2.5%. Due to its high prevalence, it is considered a worldwide problem as it is also associated with significant disability.
In most instances, a herniated disc occurs due to the natural aging process in the intervertebral disc. Due to the disc degeneration, the amount of water that was previously seen in the intervertebral disc gets dried out leading to the shrinking of the disc with the narrowing of the intervertebral space. These changes are markedly seen in degenerative disc disease. In addition to these gradual changes due to normal wear and tear, other factors may also contribute to increasing the risk of intervertebral disc herniation.
Being overweight can increase the load on the spine and increase the risk of herniation. A sedentary life can also increase the risk and therefore an active lifestyle is recommended in preventing this condition. Improper posture with prolonged standing, sitting, and especially driving can put a strain on the intervertebral discs due to the additional vibration from the vehicle engine leading to microtrauma and cracks in the disc. The occupations which require constant bending, twisting, pulling and lifting can put a strain on the back. Improper weight lifting techniques are one of the major reasons.
When back muscles are used in lifting heavy objects instead of lifting with the legs and twisting while lifting can make the lumbar discs more vulnerable to herniation. Therefore patients should always be advised to lift weights with their legs and not the back. Smoking has been thought to increase disc herniation by reducing the blood supply to the intervertebral disc leading to degenerative changes of the disc.
Although the above factors are frequently assumed to be the causes for disc herniation, some studies have shown that the difference in risk is very small when this particular population was compared with the control groups of the normal population.
There have been several types of research done on genetic predisposition and intervertebral disc herniation. Some of the genes that are implicated in this disease include vitamin D receptor (VDR) which is a gene that codes for the polypeptides of important collagen called collagen IX (COL9A2).
Another gene called the human aggrecan gene (AGC) is also implicated as it codes for proteoglycans which is the most important structural protein found in the cartilage. It supports the biochemical and mechanical function of the cartilage tissue and hence when this gene is defective, it can predispose an individual to intervertebral disc herniation.
Apart from these, there are many other genes that are being researched due to the association between disc herniation such as matrix metalloproteinase (MMP) cartilage intermediate layer protein, thrombospondin (THBS2), collagen 11A1, carbohydrate sulfotransferase, and asporin (ASPN). They may also be regarded as potential gene markers for lumbar disc disease.
Pathogenesis of Sciatica and Disc Herniation
The sciatic pain originated from the extruded nucleus pulposus inducing various phenomena. It can directly compress the nerve roots leading to ischemia or without it, mechanically stimulate the nerve endings of the outer portion of the fibrous ring and release inflammatory substances suggesting its multifactorial origin. When the disc herniation causes mechanical compression of the nerve roots, the nerve membrane is sensitized to pain and other stimuli due to ischemia. It has been shown that in sensitized and compromised nerve roots, the threshold for neuronal sensitization is around half of that of a normal and non-compromised nerve root.
The inflammatory cell infiltration is different in extruded discs and non-extruded discs. Usually, in non-extruded discs, the inflammation is less. The extruded disc herniation causes the posterior longitudinal ligament to rupture which exposes the herniated part to the vascular bed of the epidural space. It is believed that inflammatory cells are originating from these blood vessels situated in the outermost part of the intervertebral disc.
These cells may help secrete substances that cause inflammation and irritation of the nerve roots causing sciatic pain. Therefore, extruded herniations are more likely to cause pain and clinical impairment than those that are contained. In contained herniations, the mechanical effect is predominant while in the unconfined or the extruded discs the inflammatory effect is predominant.
Clinical Disc Herniation and What to Look for in the History
The symptoms of the disc herniation can vary a great deal depending on the location of the pain, the type of herniation, and the individual. Therefore, history should focus on the analysis of the main complaint among the many other symptoms.
The chief complaint can be neck pain in cervical disc herniation and there can be referred pain in the arms, shoulders, neck, head, face, and even the lower back region. However, it is most commonly referred to as the interscapular region. The radiation of pain can occur according to the level at the herniation is taking place. When the nerve roots of the cervical region are affected and compressed, there can be sensory, and motor changes with changes in the reflexes.
The pain that occurs due to nerve root compression is called radicular pain and it can be described as deep, aching, burning, dull, achy, and electric depending on whether there is mainly motor dysfunction or sensory dysfunction. In the upper limb, the radicular pain can follow a dermatomal or myotomal pattern. Radiculopathy usually does not accompany neck pain. There can be unilateral as well as bilateral symptoms. These symptoms can be aggravated by activities that increase the pressure inside the intervertebral discs such as the Valsalva maneuver and lifting.
Driving can also exacerbate pain due to disc herniation due to stress because of vibration. Some studies have shown that shock loading and stress from vibration can cause a mechanical force to exacerbate small herniations but flexed posture had no influence. Similarly, activities that decrease intradiscal pressure can reduce the symptoms such as lying down.
The main complaint in lumbar disc herniation is lower back pain. Other associated symptoms can be a pain in the thigh, buttocks, and anogenital region which can radiate to the foot and toe. The main nerve affected in this region is the sciatic nerve causing sciatica and its associated symptoms such as intense pain in the buttocks, leg pain, muscle weakness, numbness, impairment of sensation, hot and burning or tingling sensation in the legs, dysfunction of gait, impairment of reflexes, edema, dysesthesia or paresthesia in the lower limbs. However, sciatica can be caused by causes other than herniation such as tumors, infection, or instability which need to be ruled out before arriving at a diagnosis.
The herniated disc can also compress on the femoral nerve and can give rise to symptoms such as numbness, tingling sensation in one or both legs, and a burning sensation in the legs and hips. Usually, the nerve roots that are affected in herniation in the lumbar region are the ones exiting below the intervertebral disc. It is thought that the level of the nerve root irritation determines the distribution of leg pain. In herniations at the third and fourth lumbar vertebral levels, the pain may radiate to the anterior thigh or the groin. In radiculopathy at the level of the fifth lumbar vertebra, the pain may occur in the lateral and anterior thigh region. In herniations at the level of the first sacrum, the pain may occur in the bottom of the foot and the calf. There can also be numbness and tingling sensation occurring in the same area of distribution. The weakness in the muscles may not be able to be recognized if the pain is very severe.
When changing positions the patient is often relieved from pain. Maintaining a supine position with the legs raised can improve the pain. Short pain relief can be brought by having short walks while long walks, standing for prolonged periods, and sitting for extended periods of time such as in driving can worsen the pain.
The lateral disc herniation is seen in foraminal and extraforaminal herniations and they have different clinical features to that of medial disc herniation seen in subarticular and central herniations. The lateral intervertebral disc herniations can when compared to medial herniations more directly irritate and mechanically compress the nerve roots that are exiting and the dorsal root ganglions situated inside the narrowed spinal canal.
Therefore, lateral herniation is seen more frequently in older age with more radicular pain and neurological deficits. There is also more radiating leg pain and intervertebral disc herniations in multiple levels in the lateral groups when compared to medial disc herniations.
The herniated disc in the thoracic region may not present with back pain at all. Instead, there are predominant symptoms due to referred pain in the thorax due to irritation of nerves. There can also be predominant pain in the body that travels to the legs, tingling sensation and numbness in one or both legs, muscle weakness, and spasticity of one or both legs due to exaggerated reflexes.
The clinician should look out for atypical presentations as there could be other differential diagnoses. The onset of symptoms should be inquired about to determine whether the disease is acute, sub-acute, or chronic in onset. Past medical history has to be inquired about in detail to exclude red flag symptoms such as pain that occurs at night without activity which can be seen in pelvic vein compression, and non-mechanical pain which may be seen in tumors or infections.
If there is a progressive neurological deficit, with bowel and bladder involvement is there, it is considered a neurological emergency and urgently investigated because cauda equine syndrome may occur which if untreated, can lead to permanent neurological deficit.
Getting a detailed history is important including the occupation of the patient as some activities in the job may be exacerbating the patient’s symptoms. The patient should be assessed regarding which activities he can and cannot do.
Degenerative disc disease
Myofascial pain leading to sensory disturbances and local or referred pain
Cyst leading to occasional motor deficits and sensory disturbances
Spondylosis or spondylolisthesis
Discitis or osteomyelitis
Malignancy, neurinoma or mass lesion causing atrophy of thigh muscles, glutei
Spinal stenosis is seen mainly in the lumbar region with mild low back pain, motor deficits, and pain in one or both legs.
An epidural abscess can cause symptoms similar to radicular pain involving spinal disc herniation
Aortic aneurysm which can cause low back pain and leg pain due to compression can also rupture and lead to hemorrhagic shock.
Hodgkin’s lymphoma in advanced stages can lead to space-occupying lesions in the spinal column leading to symptoms like that of intervertebral disc herniation
Lumbar nerve root schwannoma
Herpes zoster infection results in inflammation along with the sciatic or lumbosacral nerve roots
Examination in Disc Herniation
Complete physical examination is necessary to diagnose intervertebral disc herniation and exclude other important differential diagnoses. The range of motion has to be tested but may have a poor correlation with disc herniation as it is mainly reduced in elderly patients with a degenerative disease and due to disease of the joints.
A complete neurological examination is often necessary. This should test muscle weakness and sensory weakness. In order to detect muscle weakness in small toe muscles, the patient can be asked to walk on tiptoe. The strength of muscle can also be tested by comparing the strength to that of the clinician. There may be dermatomal sensory loss suggesting the respective nerve root involvement. The reflexes may be exaggerated or sometimes maybe even absent.
There are many neurologic examination maneuvers described in relation to intervertebral disc herniation such as the Braggart sign, flip the sign, Lasegue rebound sign, Lasegue differential sign, Mendel Bechterew sign, Deyerle sign both legs or Milgram test, and well leg or Fajersztajin test. However, all these are based on testing the sciatic nerve root tension by using the same principles in the straight leg raising test. These tests are used for specific situations to detect subtle differences.
Nearly almost all of them depend on the pain radiating down the leg and if it occurs above the knee it is assumed to be due to a neuronal compressive lesion and if the pain goes below the knee, it is considered to be due to the compression of the sciatic nerve root. For lumbar disc herniation detection, the most sensitive test is considered to be radiating pain occurring down the leg due to provocation.
In the straight leg raising test also called the Lasegue’s sign, the patient stays on his or her back and keeps the legs straight. The clinician then lifts the legs by flexing the hip while keeping the knee straight. The angle at which the patient feels pain going down the leg below the knee is noted. In a normal healthy individual, the patient can flex the hip to 80- 90? without having any pain or difficulty.
However, if the angle is just 30 -70? degrees, it is suggestive of lumbar intervertebral disc herniation at the L4 to S1 nerve root levels. If the angle of hip flexion without pain is less than 30 degrees, it usually indicates some other causes such as tumor of the gluteal region, gluteal abscess, spondylolisthesis, disc extrusion, and protrusion, malingering patient, and acute inflammation of the dura mater. If pain with hip flexion occurs at more than 70 degrees, it may be due to tightness of the muscles such as gluteus maximus and hamstrings, tightness of the capsule of the hip joint, or pathology of sacroiliac or hip joints.
The reverse straight leg raising test or hip extension test can be used to test higher lumbar lesions by stretching the nerve roots of the femoral nerve which is similar to the straight leg raising test. In the cervical spine, in order to detect stenosis of the foramina, the Spurling test is done and is not specific to cervical intervertebral disc herniation or tension of the nerve roots. The Kemp test is the analogous test in the lumbar region to detect foraminal stenosis. Complications due to the disc herniation include careful examination of the hip region, digital rectal examination, and urogenital examination is needed.
Investigation of Disc Herniation
For the diagnosis of intervertebral disc herniation, diagnostic tests such as Magnetic resonance imaging (MRI), Computed tomography (CT), myelography, and plain radiography can be used either alone or in combination with other imaging modalities. Objective detection of disc herniation is important because only after such a finding the surgical intervention is even considered. Serum biochemical tests such as prostate-specific antigen (PSA) level, Alkaline phosphatize value, erythrocyte sedimentation rate (ESR), urine analysis for Bence Jones protein, serum glucose level, and serum protein electrophoresis may also be needed in specific circumstances guided by history.
Magnetic Resonance Imaging (MRI)
MRI is considered the best imaging modality in patients with history and physical examination findings suggestive of lumbar disc herniation associated with radiculopathy according to North American Spinal Society guidelines in 2014. The anatomy of the herniated nucleus pulposus and its associated relationships with soft tissue in the adjacent areas can be delineated exquisitely by MRI in cervical, thoracic, and lumbosacral areas. Beyond the confines of the annulus, the herniated nucleus can be seen as a focal, asymmetric disc material protrusion on MRI.
On sagittal T2 weighted images, the posterior annulus is usually seen as a high signal intensity area due to radial annular tear associated with the herniation of the disc although the herniated nucleus is itself hypointense. The relationship between the herniated nucleus and degenerated facets with the nerve roots which are exiting through the neural foramina are well-demarcated on sagittal images of MRI. Free fragments of the intervertebral disc can also be distinguished from MRI images.
There may be associated signs of intervertebral disc herniation on MRI such as radial tears on the annulus fibrosus which is also a sign of degenerative disc disease. There may be other telling signs such as loss of disc height, bulging annulus, and changes in the endplates. Atypical signs may also be seen with MRI such as abnormal disc locations, and lesions located completely outside the intervertebral disc space.
MRI can detect abnormalities in the intervertebral discs superiorly to other modalities although its bone imaging is a little less inferior. However, there are limitations with MRI in patients with metal implant devices such as pacemakers because the electromagnetic field can lead to abnormal functioning of the pacemakers. In patients with claustrophobia, it may become a problem to go to the narrow canal to be scanned by the MRI machine. Although some units contain open MRI, it has less magnetic power and hence delineates less superior quality imaging.
This is also a problem in children and anxious patients undergoing MRI because good image quality depends on the patient staying still. They may require sedation. The contrast used in MRI which is gadolinium can induce nephrogenic systemic fibrosis in patients who had pre-existing renal disease. MRI is also generally avoided in pregnancy especially during the first 12 weeks although it has not been clinically proven to be hazardous to the fetus. MRI is not very useful when a tumor contains calcium and in distinguishing edema fluid from tumor tissue.
Computed Tomography (CT)
CT scanning is also considered another good method to assess spinal disc herniation when MRI is not available. It is also recommended as a first-line investigation in unstable patients with severe bleeding. CT scanning is superior to myelography although when the two are combined, it is superior both of them. CT scans can show calcification more clearly and sometimes even gas in images. In order to achieve a superior imaging quality, the imaging should be focused on the site of pathology and thin sections taken to better determine the extent of the herniation.
However, a CT scan is difficult to be used in patients who have already undergone laminectomy surgical procedures because the presence of scar tissue and fibrosis causes the identification of the structures difficult although bony changes and deformity in nerve sheath are helpful in making a diagnosis.
The herniated intervertebral discs in the cervical disc can be identified by studying the uncinate process. It is usually projected posteriorly and laterally to the intervertebral discs and superiorly to the vertebral bodies. The uncinate process undergoes sclerosis, and hypertrophy when there is an abnormal relationship between the uncinate process and adjacent structures as seen in degenerative disc disease, intervertebral disc space narrowing, and general wear and tear.
Myelopathy can occur when the spinal canal is affected due to disc disease. Similarly, when neural foramina are involved, radiculopathy occurs. Even small herniated discs and protrusions can cause impingement of the dural sac because the cervical epidural space is narrowed naturally. The intervertebral discs have attenuation a little bit greater than the sac characterized in the CT scan.
In the thoracic region, a CT scan can diagnose an intervertebral disc herniation with ease due to the fact that there is an increased amount of calcium found in the thoracic discs. Lateral to the dural sac, the herniated disc material can be seen on CT as a clearly defined mass that is surrounded by epidural fat. When there is a lack of epidural fat, the disc appears as a higher attenuated mass compared to the surrounding.
Plain radiography is not needed in diagnosing herniation of the intervertebral discs, because plain radiographs cannot detect the disc and therefore are used to exclude other conditions such as tumors, infections, and fractures.
In myelography, there may be deformity or displacement of the extradural contrast-filled thecal sac seen in herniation of the disc. There may also be features in the affected nerve such as edema, elevation, deviation, and amputation of the nerve root seen in the myelography image.
In this imaging modality, the contrast medium is injected into the disc in order to assess the disc morphology. If pain occurs following injection that is similar to the discogenic pain, it suggests that that disc is the source of the pain. When a CT scan is also performed immediately after discography, it is helpful to differentiate the anatomy and pathological changes. However, since it is an invasive procedure, it is indicated only in special circumstances when MRI and CT have failed to reveal the etiology of back pain. It has several side effects such as headache, meningitis, damage to the disc, discitis, intrathecal hemorrhage, and increased pain.
Treatment of Herniated Disc
The treatment should be individualized according to the patient-guided through history, physical examination, and diagnostic investigation findings. In most cases, the patient gradually improves without needing further intervention in about 3 – 4 months. Therefore, the patient only needs conservative therapy during this time period. Because of this reason, there are many ineffective therapies that have emerged by attributing the natural resolution of symptoms to that therapy. Therefore, conservative therapy needs to be evidence-based.
Since the herniation of the disc has a benign course, the aim of treatment is to stimulate the recovery of neurological function, reduce pain, and facilitate early return to work and activities of daily living. The most benefits of the conservative treatment are for younger patients with hernias that are sequestered and in patients with mild neurological deficits due to small disc hernias.
Bed rest has long been considered a treatment option in herniation of the disc. However, it has been shown that bed rest has no effect beyond the first 1 or 2 days. The bed rest is regarded as counterproductive after this period of time.
In order to reduce the pain, oral non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen can be used. This can relieve the pain by reducing inflammation associated with the inflamed nerve. Analgesics such as acetaminophen can also be used although they lack the anti-inflammatory effect seen in NSAIDs. The doses and the drugs should be appropriate for the age and severity of the pain in the patient. If pain is not controlled by the current medication, the clinician has to go one step up on the WHO analgesics ladder. However, the long-term use of NSAIDs and analgesics can lead to gastric ulcers, liver, and kidney problems.
In order to reduce the inflammation, other alternative methods such as applying ice in the initial period and then switching to using heat, gels, and rubs may help with the pain as well as muscle spasms. Oral muscle relaxants can also be used in relieving muscle spasms. Some of the drugs include methocarbamol, carisoprodol, and cyclobenzaprine.
However, they act centrally and cause drowsiness and sedation in patients and it does not act directly to reduce muscle spasm. A short course of oral steroids such as prednisolone for a period of 5 days in a tapering regime can be given to reduce the swelling and inflammation in the nerves. It can provide immediate pain relief within a period of 24 hours.
When the pain is not resolved adequately with maximum effective doses, the patient can be considered for giving steroid injections into the epidural space. The major indication for the steroid injection into periradicular space is discal compression causing radicular pain that is resistant to conventional medical treatment. A careful evaluation with CT or MRI scanning is required to carefully exclude extra discal causes for pain. The contraindications for this therapy include patients with diabetes, pregnancy, and gastric ulcers. Epidural puncture is contraindicated in patients with coagulation disorders and therefore the foraminal approach is used carefully if needed.
This procedure is performed under the guidance of fluoroscopy and involves injecting steroids and an analgesic into the epidural space adjacent to the affected intervertebral disc to reduce the swelling and inflammation of the nerves directly in an outpatient setting. As much as 50% of the patients experience relief after the injection although it is temporary and they might need repeat injections at 2 weekly intervals to achieve the best results. If this treatment modality becomes successful, up to 3 epidural steroidal injections can be given per year.
Physical therapy can help the patient return to his previous life easily although it does not improve the herniated disc. The physical therapist can instruct the patient on how to maintain the correct posture, walking, and lifting techniques depending on the patient’s ability to work, mobility, and flexibility.
Stretching exercises can improve the flexibility of the spine while strengthening exercises can increase the strength of the back muscles. The activities which can aggravate the condition of the herniated disc are instructed to be avoided. Physical therapy makes the transition from intervertebral disc herniation to an active lifestyle smooth. The exercise regimes can be maintained for life to improve general well-being.
The most effective conservative treatment option that is evidence-based is observation and epidural steroid injection for the relief of pain in the short-term duration. However, if the patients so desire they can use holistic therapies of their choice with acupuncture, acupressure, nutritional supplements, and biofeedback although they are not evidence-based. There is also no evidence to justify the use of trans electrical nerve stimulation (TENS) as a pain relief method.
If there is no improvement in the pain after a few months, surgery can be contemplated and the patient must be selected carefully for the best possible outcome.
The aim of surgical therapy is to decompress the nerve roots and relieve the tension. There are several indications for surgical treatment which are as follows.
Absolute indications include cauda equina syndrome or significant paresis. Other relative indications include motor deficits that are greater than grade 3, sciatica that is not responding to at least six months of conservative treatment, sciatica for more than six weeks, or nerve root pain due to foraminal bone stenosis.
There have been many discussions over the past few years regarding whether to treat herniation of intervertebral disc disease with prolonged conservative treatment or early surgical treatment. Much research has been conducted in this regard and most of them show that the final clinical outcome after 2 years is the same although the recovery is faster with early surgery. Therefore, it is suggested that early surgery may be appropriate as it enables the patient to return to work early and thereby is economically feasible.
Some surgeons may still use traditional discectomy although many are using minimally invasive surgical techniques over recent years. Microdiscectomy is considered to be the halfway between the two ends. There are two surgical approaches that are being used. Minimally invasive surgery and percutaneous procedures are the ones that are being used due to their relative advantage. There is no place for the traditional surgical procedure known as a laminectomy.
However, there are some studies suggesting microdiscectomy is more favorable because of its both short-term and long-term advantages. In the short term, there is a reduced length of operation, reduced bleeding, relief of symptoms, and reduced complication rate. This technique has been effective even after 10 years of follow-up and therefore is the most preferred technique even now. The studies that have been performed to compare the minimally invasive technique and microdiscectomy have resulted in different results. Some have failed to establish a significant difference while one randomized control study was able to determine that microdiscectomy was more favorable.
In microdiscectomy, only a small incision is made aided by an operating microscope and the part of the herniated intervertebral disc fragment which is impinging on the nerve is removed by hemilaminectomy. Some part of the bone is also removed to facilitate access to the nerve root and the intervertebral disc. The duration of the hospital stay is minimal with only an overnight stay and observation because the patient can be discharged with minimal soreness and complete relief of the symptoms.
However, some unstable patients may need more prolonged admission and sometimes they may need fusion and arthroplasty. It is estimated that about 80 – 85 % of the patients who undergo microdiscectomy recover successfully and many of them are able to return to their normal occupation in about 6 weeks.
There is a discussion on whether to remove a large portion of the disc fragment and curetting the disc space or to remove only the herniated fragment with minimal invasion of the intervertebral disc space. Many studies have suggested that the aggressive removal of large chunks of the disc could lead to more pain than when conservative therapy is used with 28% versus 11.5 %. It may lead to degenerative disc disease in the long term. However, with conservative therapy, there is a greater risk of recurrence of around 7 % in herniation of the disc. This may require additional surgery such as arthrodesis and arthroplasty to be performed in the future leading to significant distress and economic burden.
In the minimally invasive surgery, the surgeon usually makes a tiny incision in the back to put the dilators with increasing diameter to enlarge the tunnel until it reaches the vertebra. This technique causes lesser trauma to the muscles than when seen in traditional microdiscectomy. Only a small portion of the disc is removed in order to expose the nerve root and the intervertebral disc. Then the surgeon can remove the herniated disc by the use of an endoscope or a microscope.
These minimally invasive surgical techniques have a higher advantage of lower surgical site infections and shorter hospital stays. The disc is centrally decompressed either chemically or enzymatically with the use of chymopapain, laser, or plasma (ionized gas) ablation and vaporization. It can also be decompressed mechanically by using percutaneous lateral decompression or by aspirating and sucking with a shaver such as a nucleosome. Chemopapin was shown to have adverse effects and was eventually withdrawn. Most of the above techniques have shown to be less effective than a placebo. Directed segmentectomy is the one that has shown some promise in being effective similar to microdiscectomy.
In the cervical spine, the herniated intervertebral discs are treated anteriorly. This is because the herniation occurs anteriorly and the manipulation of the cervical cord is not tolerated by the patient. The disc herniation that is due to foraminal stenosis and that is confined to the foramen are the only instances where a posterior approach is contemplated.
The minimal disc excision is an alternative to the anterior cervical spine approach. However, the intervertebral disc stability after the procedure is dependent on the residual disc. The neck pain can be significantly reduced following the procedure due to the removal of neuronal compression although significant impairment can occur with residual axial neck pain. Another intervention for cervical disc herniation includes anterior cervical interbody fusion. It is more suitable for patients with severe myelopathy with degenerative disc disease.
Complications of the Surgery
Although the risk of surgery is very low, complications can still occur. Post-operative infection is one of the commonest complications and therefore needs more vigorous infection control procedures in the theatre and in the ward. During the surgery, due to poor surgical technique, nerve damage can occur. A dural leak may occur when an opening in the lining of the nerve root causes leakage of cerebrospinal fluid which is bathing the nerve roots. The lining can be repaired during the surgery. However, headache can occur due to loss of cerebrospinal fluid but it usually improves with time without any residual damage. If blood around the nerve roots clots after the surgery, that blood clot may lead to compression of the nerve root leading to radicular pain which was experienced by the patient previously. Recurrent herniation of the intervertebral disc due to herniation of disc material at the same site is a devastating complication that can occur long term. This can be managed conservatively but surgery may be necessary ultimately.
Outcomes of the Surgery
There has been extensive research done regarding the outcome of lumbar disc herniation surgery. Generally, the results from the microdiscectomy surgery are good. There is more improvement of leg pain than back pain and therefore this surgery is not recommended for those who have only back pain. Many patients improve clinically over the first week but they may improve over the following several months. Typically, the pain disappears in the initial recovery period and it is followed by an improvement in the strength of the leg. Finally, the improvement of the sensation occurs. However, patients may complain of feeling numbness although there is no pain. The normal activities and work can be resumed over a few weeks after the surgery.
Although conservative therapy is the most appropriate therapy in treating patients, the current standard of care does not address the underlying pathology of herniation of the intervertebral discs. There are various pathways that are involved in the pathogenesis such as inflammatory, immune-mediated, and proteolytic pathways.
The role of inflammatory mediators is currently under research and it has led to the development of new therapies that are directed at these inflammatory mediators causing damage to the nerve roots. The cytokines such as TNF ? are mainly involved in regulating these processes. The pain sensitivity is mediated by serotonin receptor antagonists and ?2 adrenergic receptor antagonists.
Therefore, pharmacological therapies that target these receptors and mediators may influence the disease process and lead to a reduction in symptoms. Currently, cytokine antagonists against TNF ? and IL 1? have been tested. Neuronal receptor blockers such as sarpogrelate hydrochloride etc have been tested in both animal models and in clinical studies for the treatment of sciatica. Cell cycle modifiers that target the microglia that are thought to initiate the inflammatory cascade have been tested with the neuroprotective antibiotic minocycline.
There is also research on inhibiting the NF- kB or protein kinase pathway recently. In the future, the treatment of herniation of the intervertebral disc will be much more improved thanks to the ongoing research. (Haro, Hirotaka)
Dr. Alex Jimenez DC, MSACP, RN, CCST
A disc bulge and/or a herniated disc is a health issue that affects the intervertebral discs found in between each vertebra of the spine. Although these can occur as a natural part of degeneration with age, trauma or injury as well as repetitive overuse can also cause a disc bulge or a herniated disc. According to healthcare professionals, a disc bulge and/or a herniated disc is one of the most common health issues affecting the spine. A disc bulge is when the outer fibers of the annulus fibrosus are displaced from the margins of the adjacent vertebral bodies. A herniated disc is when a part of or the whole nucleus pulposus is protruded through the torn or weakened outer annulus fibrosus of the intervertebral disc. Treatment of these health issues focuses on reducing symptoms. Alternative treatment options, such as chiropractic care and/or physical therapy, can help relieve symptoms. Surgery may be utilized in cases of severe symptoms. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
Curated by Dr. Alex Jimenez D.C., C.C.S.T.
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Kinesthesia is the body’s ability to sense movement, position, action, and location, also known as proprioception. An example is when moving the arm, the brain and body are aware that the arm has moved. When dealing with chronic back pain, individuals are unable to function normally with regular everyday movements causing discomfort.
Chronic back pain can make an individual feel like a stranger in their body, altering their perception. Tension develops throughout the body due to the pain, causing tightness and positional adaptations that are unfamiliar, awkward, and unhealthy for the musculoskeletal system. These body positioning changes continue while the individual is unaware of what they are doing, causing further strain and injury.
Kinesthesia is essential for overall coordination, balance, and posture as long as the movements are done correctly with proper form. Chronic back pain can affect kinesthesia differently. Individuals can misjudge and estimate that their bodies’ ability to lift, carry, or open something is more complicated or easier than it is. This can exceed the body’s tolerances, causing:
Once the back starts to hurt, this causes the individual’s sense of kinesthesia to compensate for the pain. As a result, individuals may knowingly or unknowingly attempt to carry out uncoordinated, awkward movements and positions, making things worse.
Motor control is the ability to control movement. When experiencing back pain, individuals adjust their motor control to avoid specific movements that cause back pain. Motor control adaptations and kinesthesia involve body positioning and heightened responsiveness to stimuli, like muscle spasms. Even moderate back pain can cause awkward and dangerous responses causing individuals to overcompensate or become too cautious, worsening or creating new injuries in the process. The body is performing movements that do not follow proper form, even though an individual thinks they are protecting themselves.
Building Healthy Proprioception
A recommended strategy for building kinesthesia to benefit the back and the rest of the body is yoga. Yoga helps build bodily sensory awareness. It trains the body when sending significant signals from the muscles, joints, and tendons back to the proprioceptive centers in the brain. This happens immediately and increases over time.
Creating positive awareness of the body’s movements will help relieve back pain as the body learns to feel, understand, and control the muscles. Here are a few poses to help, along with video links.
Body awareness is critical, but if an individual moves in a way that’s not natural to the body, it can cause injury. Kinesthesia and healthy posture can help avoid back pain and other health issues. A professional chiropractor can alleviate back pain, educate on proper form and recommend specific stretches and exercises to strengthen the body to prevent injury.
Magnesium supports a healthy immune system. It helps maintain:
Healthy bone structure
Magnesium assists the body with ATP energy metabolism and acts as a calcium blocker. This reduces cramping and aids in muscle relaxation after physical activity/exercise. Magnesium is essential in biochemical reactions in the body. A slight deficiency can lead to an increased risk of cardiovascular disease and a higher risk of insulin resistance. Many magnesium-rich foods are high in fiber, like:
Studies have shown that consuming a diet rich in Magnesium also provides a higher intake of dietary fiber. Dietary fiber aids in:
Helps control weight
Stabilizes blood sugar
The best sources of Magnesium include:
Spinach, swiss chard, and turnip greens
Almonds and cashews
Flax, pumpkin, and chia seeds
Meier, Michael Lukas et al. “Low Back Pain: The Potential Contribution of Supraspinal Motor Control and Proprioception.” The Neuroscientist: a review journal bringing neurobiology, neurology and psychiatry vol. 25,6 (2019): 583-596. doi:10.1177/1073858418809074
Tong, Matthew Hoyan et al. “Is There a Relationship Between Lumbar Proprioception and Low Back Pain? A Systematic Review With Meta-Analysis.” Archives of physical medicine and rehabilitation vol. 98,1 (2017): 120-136.e2. doi:10.1016/j.apmr.2016.05.016
Wang, Jinsong, et al. “Dietary magnesium intake improves insulin resistance among non-diabetic individuals with metabolic syndrome participating in a dietary trial.” Nutrients vol. 5,10 3910-9. 27 Sep. 2013, doi:10.3390/nu5103910
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