Dr. Alex Jmenez, Chiropractor Discusses: Spinal Decompression Therapies, Protocols, Rehabilitation and Advance Treatments Care Plans
At our offices, we offer conservative care for degenerative spinal conditions, including several treatment modalities. Thus, the traction distinguishes as it can elicit the body’s protective proprioceptive response to distraction, reducing intradiscal pressure and minimizing symptoms secondary to disc herniation and axial pain.
Our integrative treatments aim to determine the clinical effects of a short treatment course of motorized axial spinal decompression for patients with pain and physical impairment caused by either lumbar or cervical degenerative disc pathology with no immediate surgical indication.
Conservative care for mid to long-term degenerative spinal conditions with axial and irradiated pain generally includes pharmacological treatment, physical rehabilitation, or injections. Mechanical traction is an old treatment modality, which has been decreased in use facing other modern technologies or utilized in combination with other treatment modalities, such as manual therapy, exercises, heat, or electrotherapy. We, too, offer advanced spinal treatment workshops and boot camps to help educate patients on the dynamics of spinal hygiene.
Our patients get treated for chronic radicular axial spinal pain. This is a referred pain in the spinal axial skeleton and is considered a syndrome with both nociceptive and neuropathic pain components. Patients report improvement in symptoms with a reduction of the axial load in the spine.
Previous studies have shown a decrease of pressure in the intervertebral disc after traction, unloading of the spinal structure, and alleviating the inflammatory reaction of the nerve roots. Here, we present our patients’ literature and scientific background information to make educated decisions about the advanced spinal decompression protocols.
If you’re looking for a non-surgical solution for your persistent back or leg pain, you may want to try spinal decompression therapy. Unlike invasive or laparoscopic surgeries, spinal decompression does not require the patient to go under the knife. Instead, the patient’s spine is stretched to relieve back and leg pain. The goal of spinal decompression is to create an ideal healing environment for the affected areas.
This treatment is typically used for:
Bulging discs
Degenerating discs
Herniated discs
Call us today to schedule your first appointment! Our team in El Paso is happy to help.
Athletes and fitness enthusiasts work hard to stay in shape, but they are also at an increased risk for a lumbar hyperextension injury. Lumbar hyperextension injuries happen when the low back is bent backward repeatedly or overarches repeatedly. The repetitive stress can lead to severe complications and damage the nerves, vertebrae, and backbones. Motorized decompression therapy could be a treatment option.
Lumbar Hyperextension Injury
Injuries can be caused by overuse, improper mechanics and technique, lack of proper conditioning, insufficient stretching, or trauma. When looking for symptoms of lumbar hyperextension injuries, the first is low back pain that is severe and lasts at least a few days while becoming more intense with time. The lower back pain that worsens when extending, or arching the back, in addition to stiffness, muscle spasms, radiating buttock and thigh pain, tight hamstrings, and difficulty standing or walking, can be indicators of a lumbar hyperextension injury. However, this could be difficult to distinguish from other injuries like muscle strain, disc herniation, and stenosis; this is why a proper examination by a medical professional is recommended.
Treatment
Initial treatment consists of resting, sitting out from the sport, and other activities that could aggravate the back.
A doctor may recommend over-the-counter non-steroidal anti-inflammatory medications.
Heat and ice can also be used to increase circulation and relieve pain.
If hyperextension of the back continues even after rest, it could signify a stress fracture in the vertebrae. This condition is referred to as spondylolysis.Spondylolysis is an overuse injury. It occurs in individuals who participate in sports like gymnastics, diving, volleyball, football, and weight lifting. Spondylolysis and spondylolisthesis are common in adolescent athletes experiencing lower back pain.
A doctor may assign a back brace to prevent movement, allowing the bone to heal back together.
A doctor could also recommend physical therapy for 6-12 weeks after the diagnosis and once the bones have had time to heal.
Rehabilitation exercises focus on improving back flexibility and strength.
Athletes can be cleared to return to their sport within 3-6 months.
Surgery is rarely necessary and only looked into if the individual continues to have persistent pain after 6-12 months of treatment.
This changes the spine’s position, takes the pressure off the nerves and discs, and restores the cushioning.
As the machine pulls the body, a vacuum effect fills the discs with oxygen and nutrients to stimulate healing.
Computer technology controls treatment duration, angle, intensity, and relaxation.
Prevention
Athletes and fitness enthusiasts are recommended to seek professional help to retrain how they perform repetitive and excessive high-impact activities. Specifically, those involving hyperextension movements like kicking, jumping, running, and back bending help minimize the risk of developing a back injury. They are also recommended to maintain body conditioning, back and hamstring flexibility, core muscle strength and endurance, cardiovascular fitness, and properly warming up and stretching before and after the physical activities.
DOC Decompression Table
References
Ball, J.R., Harris, C.B., Lee, J. et al. Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations. Sports Med – Open 5, 26 (2019). doi.org/10.1186/s40798-019-0199-7
Carter, D R, and V H Frankel. “Biomechanics of hyperextension injuries to the cervical spine in football.” The American journal of sports medicine vol. 8,5 (1980): 302-9. doi:10.1177/036354658000800502
Goetzinger, Sara, et al. “Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management.” Journal of sports medicine (Hindawi Publishing Corporation) vol. 2020 9235958. 21 Jan. 2020, doi:10.1155/2020/9235958
Lawrence, Kevin J et al. “Lumbar spondylolysis in the adolescent athlete.” Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine vol. 20 (2016): 56-60. doi:10.1016/j.ptsp.2016.04.003
Dr. Alex Jimenez DC talks with Dr. Brian Self DC about the beneficial properties of spinal decompression therapy and how it can alleviate many individuals dealing with low back pain. Spinal decompression therapy utilizes traction by gently stretching the spine, allowing the nutrients to go back into the spine. By referring patients to qualified and skilled providers specializing in spinal decompression therapy. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable 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, please call Dr. Jimenez at 915-850-0900.
[00:01:10] Dr. Alex Jimenez DC: I can. Yes, indeed. We’ve got Rob on. We just have a few other people just kind of pile on in here. And I’ll just keep allowing him to come in as we go. But guys, we’ll get started here now. We’re about one minute past 12:30, but I asked Dr. Self to be on. Many of you have met him already in regards to the doc tables. Dr. Self, we have a couple of offices on this call that runs decompression, not necessarily the DOC table. I’d be in one of them, but I’m ordering a doc table. So we’ve had everybody hop on this call because, the information you can share, you have more clinical and business experience with decompression than any of us and all of us combined. So I wanted to get you on a call with everybody that we have up here in the Midwest now recording some of the docs that could make it so we can make all kind of start off as a good baseline of, you know, some of the teachings that you’ve given to individuals over time and what DOC table you get them rolling with it. We still run into some consistent questions from doctors. Maybe there’s a little confusion, so I wanted to bring you on so so docs can answer or ask you questions so you can answer those. And then we’ll just kind of muddle through probably three or four different topics on this call and then open it up. And I want to open up Q&A the whole time docs, whatever questions you have if there’s anything pressing you’re dealing with right now. Any questions you have will be great for the rest of us to hear. So I gave Dr. Self a little heads up on some of the questions we talked about on our first call and some of the things he’s working on for us, such as the cheat sheet. Or what do we call on that the flow chart? The flow chart, so Dr. Self’s working on that right now, and we’re excited to get that to you here shortly. Still, one of the first topics that we had on the list was the proper diagnosis in diagnosing and what protocol or the appropriate protocol. So, Dr. Brian, if you want to start, maybe there with your experience and share a little bit, and then docs, if you have any questions, unmute and fire away. So it’s going to be an open forum.
[00:03:23] Dr. Brian Self DC: All right. Thanks. Yeah, as far as diagnosis goes, you know, many people always ask, Well, do I need an MRI? I can’t do it without an MRI. I would say starting. They’re just my opinion, as most of these patients don’t need an MRI. As long as you feel like it’s not something weird or more severe, you wouldn’t want to miss multiple myeloma or pathologic aortic aneurysm or something that would be an absolute contraindication to care. So if you feel like it’s pretty straightforward, my own opinion is I tell patients, you know, give me two weeks, let’s treat every day for two weeks. And if we don’t have any results by the end of the second week, maybe let’s get an MRI. The vast majority of patients will see some sort of relief if you do it every day for two weeks. Most patients will feel a little bit of relief to the point where an MRI is probably not necessary. You can keep going and finish out the rest of the protocol. I tell patients that you can spend their time and money on a test that will probably not change how we treat this. Or you can spend your time and money on the actual treatment of the condition itself. So that’s one of the main questions that come up. But like I said, if you feel like it’s anything weird or random or you’re not quite sure, obviously get an MRI at that point; better safe than sorry. But as far as when the patients come in, you know you’re going to check their dermatomes, do their reflexes on everybody, and do muscle testing on everybody. Those are the three annual orthopedic tests. I would say that those are the four things regardless of, you know, even if you’ve seen this a thousand times. Going through those things with the patient shows them that you’re the specialist, you’re the person taking the time, the energy to find out specifically what is wrong and how can we best treat it? You know, I think that a lot of times we think that we get so good at this and maybe we are, maybe we don’t even need to do that stuff, but the patient needs to see that stuff and feel that stuff to qualify you as the specialist ready to treat this specialty type condition. So, you know, again, reflexes, dermatomes, arms, muscle testing, and then your orthopedic test will be the main ones, in my opinion. What I think that you’re looking for is, first and foremost, to make sure it’s not an absolute contraindication that care. Number two is a lot of it comes down to patient positioning. So figuring out, is this patient going to benefit from flexion? Will they benefit from the extension, or will they benefit from some lateral flexion or some lateral flexion with rotation? There have been plenty of patients that I put on a table over the years, and I had no idea what they had, but I knew that if I could find what makes it better, what makes it worse, I could recreate that on the table. Then the vast majority of the time, I could get those patients better. So certain conditions do have certain protocols that you’ll follow. For example, spondylolisthesis will be supine in full flexion with their knees up. That’s just what research has shown to be the best treatment response to spondylolisthesis. So, in general, you’ll start with full supine flexion, bringing the knees up. Grade one and grade two are fine. Grade three and grade four would be technically a contraindication for decompression. Luckily, I’ve never seen a Grade four; I think I’ve seen one grade three. And then, if you’re not sure, you can do some flexion-extension studies to see how much slippage is taking place. And then stenosis will probably be a pretty good amount of flexion, generally supine only because those patients are usually heavier and older. They’re not going to want to lie prone, for they’re not going to be prone comfortably for the entire treatment. So I usually will start those patients off supine. Now, in the rare instance that they can do prone, if you can get them comfortable, prone with your table flex down can be the most effective patient for stenosis. And the reason for that is because this is a question that we get a lot when I treat prone. I would think of when to treat prone if you have a posterior bulging disk and especially a younger patient where flexion makes it worse, and the extension makes it better. OK. There are a couple of reasons for that. Number one is when they’re prone, you have gravity working in the same direction that you want it to go. So if it’s a posterior bulging disk and they’re lying prone, you have gravity in your favor. Number two is you’re simply going to be in more extension; you can get a more true extension in the spine when they’re prone versus anything that you could do supine. One thing that is nice about the DOC table is that it is supine. You can take the table down in some extension. So if you’ve never noticed, this is one of the few tables where you would take your table up into its highest elevated position, but then lumbar flex down so that the bottom of your table is flexed down. So if a patient were supine, this would be a way to get some extension into the spine, although prone is still going to be more extension than you could ever do supine. So this would be my last choice. If a patient needs extension but can’t do prone, then the best that you would be able to do would be supine and hold down your lumbar flexion until the table is basically horizontal and then angles down. OK, so if they were supine, this would be an extension. And then again, if they were prone, this could be a position for a stenosis patient. If they could lie comfortably is the issue; this would be a good position for us to know stenosis because often of stenosis, you have a central bulging disk that’s going to be posterior. And again, any time you have a posterior bulging disk, the gravity working in the same direction, combined with the Mackensie type of protocol, you know, when they’re extended, you’ve got posterior structures, all you’ve got all your structures pushing on the posterior portion of the disk. And that is going to want to push that back into place mechanically. Combined with the negative pressure that’s generated inside the disk, when you’re doing the decompression with any sort of linear traction, you’re going to have that negative one hundred and fifty millimeters of mercury up to negative one hundred and ninety millimeters of mercury generated inside the disk as well. So, in my opinion, prone offers those three benefits, which can be far superior to supine. So it’s this kind of random. We’re going all over the place. But so again, stenosis could be either supine at flexion, what their knees up, or if tolerable, they could be prone with the table flex down. So they’re still in flexion because you want to open up that central canal; you know that full flexion will open up the Central Canal by around 20 percent. So you’re getting the benefit of the flexion combined with the benefit of the negative pressure.
[00:12:51] Dr. Alex Jimenez DC: So Brian, sum up your experience dealing with prone. So you gave us two conditions. The synoptic typically is they’ll respond favorably to that, and I understand their presentation matters as well, but stenosis and your bulging disc. Are there any other just conditions? I hate to say as a general rule, but that you be considering prone become.
[00:13:19] Dr. Brian Self DC: Yeah. And again, I think it would come down to any time extension that makes it better. Then I’m thinking prone. And so I’ll almost always take patients through just a primary range of motion, you know, bend forward and touch your toes. What does that do to the symptoms down your leg? Extend back? What does that do to the symptoms down your leg and your foot? Lean-to the left, you know, put them in the left lateral flexion? What does that do to the symptoms down your leg and your foot having to lean to the right? What does that do? What all you’re doing is just looking for what makes it better. What makes it peripheral is what makes it centralized. And then after that, you could get into some more of your specific orthopedic tests like your slumps is a perfect one. Straight leg raise. You know, all those can be a little bit beneficial sometimes. But I think to start, if you’re not sure about orthopedic tests, just look for generalities and range of motions. Sometimes I’ll even put them on their stomach, have them come up and do a Mackensie protocol, and maybe add some overpressure. OK, what does that do to the symptoms down your leg into your foot? Do you feel like those are going farther down your leg into your foot? Or do you feel like we’re making it worse in your back? And often, the only difference that they know is they say, “Yea, my legs are better, but my back is killing me. What did you do to my back?” And that’s a good thing. You know, you’re getting centralization of symptoms, which we’re always looking for. Everything comes down to what centralizes and what peripheral diseases the symptoms, and so regardless of, you know, I think a lot of times we get caught up in patient comfort, which is essential in the fact that they have to be able to lay there for twenty or twenty-three minutes, do not pull through the pain. I spent years going through the pain, just thinking, OK, if I can get them on the table and pull through that pain. They’re going to get better, and looking back on it, and I think I made a mistake early on because I didn’t have a DOC table. I had a DRX9000, which only treated supine inflection. And I think where I missed a lot of patients was not finding the exact position that centralizes the symptoms because I could only pull in one linear position inflection. And I think where this table separates itself is being able to flex the table and laterally flex with rotation. And again, a lot of that’s just going to be based on how the patient is seated in your waiting room? They’re seated in your waiting room, leaning to the left and left rotated. And that’s what’s bringing them relief. I know I’m putting the table on a left lateral flexion with the left rotation because that’s the position that their body is telling them is taking the pressure off of the nerve. So just because I know we have a wide range of people who have had a table for different times. But again, your lateral flexion will be the button on the left, so I always think l- for left is L for lateral flexion. So if we go to just the left one, we can laterally flex the table left and right. And then R for right is R for rotations. So if I squeeze just the right one, I can rotate the table left and right. I usually do one at a time just because it’s confusing to try to do both simultaneously. But if I have seen a patient walking down the hallway and holding on to the wall and they’re in the left lateral flexion with a bit of left rotation, I know I’m going to go to the left lateral flexion with the left rotation.
[00:17:39] Dr. Alex Jimenez DC: In your email, obviously starting with observation, which should be for all of us. Still, you’re taking all that in consideration of finding their intelligent posture that decreases their pain level in addition to the exam with your range of motions defined, you know whether it’s a centralized player for eyes is all that information that you’re using that to allow you to see how you’re going to set them on this table?
[00:18:02] Dr. Brian Self DC: Absolutely. The way they’re sitting in the waiting room, the way they’re walking down the hall, and then my orthopedic tests range is the motion. And then lastly is, sometimes I still have no idea at that point. Well, I’m just going to put them on a table, take them through the range of the motion on the table and see if they can tell you, OK, yeah, that feels a lot better; that’s way worse at shooting down my leg into my foot right now. Sometimes I have no idea, and I’ll just put the table in left lateral flexion and say, OK, what’s that doing to the pain down your leg? And your foot is way worse? It’s shooting down my leg right now as we speak. OK, then take it in the other direction. What’s that? Yeah, that does seem to be a little bit better. And sometimes, even at that point, patients like I don’t know. Yeah, it’s kind of better. I’m not sure. In that case, I’m just going to do an entire treatment based on what I think I should do. And I’m going to tell them, OK, tomorrow when you come back, tell me, did that seem like it made it better, worse, or the same if they come back and say that was worse, it was shooting worse than it’s ever done. Then tomorrow, during the next treatment, I will do the complete opposite. Now, keep in mind that I would only change one parameter per visit so you can keep track of exactly what’s going on. So, for example, if I’m going to do lateral flexion, I’m going to do left lateral flexion, and that’s the only parameter I’m going to change. And then tomorrow, when they come in, OK, did that make it better? Worse or the same? Oh, it was way worse. OK, today I’m going to do right lateral flexion, and then they come back. That was a little bit better. OK, now I will try some right lateral flexion with right rotation and then return. Yeah, that felt good. OK, then I might try more flexion, and they come back. That was worse than I might have so that I might put them in a more extension. They come back. That was a little bit better. And then I might try, you know, an aggressive treatment. So if I’m doing 50 pounds of force and feel like they’re just not responding the way they should, then I might go up to 70 pounds of force. And then they come back. I was so sore. Yeah, that wasn’t very pleasant. So then I know that may be more force is not the answer. So then I might try a longer treatment, but with less force. So if I was doing 50, I might try 40, but for like 30 minutes or thirty-five minutes or, you know or even like 30 pounds of force, but over like thirty-five minutes and see how they do. Many of your strictly degenerative discs will respond better to more time but less force. If you treat with too much force over too much time, you’re barely going to be able to get the patient off the table, which I’ve done hundreds of times. I just did it last week on a friend of mine. If you overtreat it, the worst-case scenario is that everything locks up and goes into spasm. You have to peel them off the table, and you have to try to get them to walk it out, which can help. But you know, you don’t want to set them back a visit. This isn’t like a lot of treatments where it’s one step backward and two steps forward. If you were doing a shockwave or a technique or something, sometimes, you will make them worse before they get better. With this, I don’t think that’s normally the case. I think you want to be better safe than sorry. Be a little bit more conservative. Less is more.male doctors in particular. Sorry, but we get in the bad habit of pulling too hard. We think that if 50 pounds of force is recommended, if I do 70, they will get better, faster. And that’s not the case with decompression, either. If you look at the research, they showed that they weren’t trying to show this. So you have to extrapolate it. But on the VAX-D, when they were treating prone, they got up to negative one hundred and ninety degrees of negative pressure of mercury generated inside the disk between about sixty-five and seventy-five pounds on their table. And then what happened was the harder they pulled. That negative pressure started going back down in most people, so at like 40 pounds of force is the minimum it took to get any negative pressure generated inside a disc. So, one thing to know is that anything below 40 pounds can still have benefits, but you’re not generating any negative pressure inside a disc. Now you’re still, you know, you’re still doing a lot of good, but you’re not getting any vacuum effect until about 40 to 45 pounds of force. And then once you know, around 50 pounds of force, it was like negative 70 millimeters of mercury. And then again, between negative around 65 to 75 pounds prone, they were at negative one hundred and ninety millimeters of mercury. But then what was interesting is once they got above that, like 85 90 pounds of force, you started to see that go back down a little bit. And again, they didn’t take it far enough. I would have loved to have seen higher amounts of force to see what happened. Would that negative pressure go back down closer to zero at a certain point if we pulled it at one hundred and fifty pounds of force? I don’t know. But I think what you can see from it, and in my opinion, there’s a sweet spot in there. You’re looking for that sweet spot of pulling hard enough to generate the most negative pressure. Still, not pulling so hard that you’re getting guarding, you’re getting spasm, which is, I think, what prevents the most amount of negative pressure from being generated. Does that make sense?
[00:24:27] Dr. Alex Jimenez DC: Yeah, I think some said to bring it back to the user every tool that you have to start with the most appropriate and applicable treatment plan, but there’s going to be some those patients that you’re just not sure. Right. So if you have a patient that you’re just not sure about, you start them on. Are you constantly starting them supine and going from there and then making some tweaks? Or what’s your general?
[00:24:56] Dr. Brian Self DC: Yeah, I do supine. I think about supine is it’s going to be the least likely to make somebody worse is going to be the most comfortable. It’s going to be the least likely to make somebody worse. At least I’ll usually start them off on the legacy one for one cycle and see how they do legacy one on one cycle is going to be about 14 minutes on the lumbar, and it’s going to be way too gentle for most people. And most people will say, I’m not feeling a lot, and that’s perfectly OK. So on supine, start them up on legacy one one cycle. If they come back for the next visit and I didn’t make them worse, I will go up one cycle per visit for the first five visits. So visit number two would be legacy number one for two cycles. Visit number three would be three cycles, and one cycle adds about three minutes per treatment. So visit number four-four cycles, visit number five five cycles. That’s going to put you around twenty-four minutes. That’s the most I would do if you’re trying to maintain 30-minute appointments. So if you’re trying to treat patients at 9:00, 9:30, 10:00, and 10:30, keep it around twenty-three minutes or less. That gives you about seven minutes to take patients on and off the table.
[00:26:27] Dr. Alex Jimenez DC: OK, so docs, any questions about anything thus far. Clarification is needed on any points. Dr. Christian, go ahead.
What To Do Before The Treatment
Dr. Christian DC and Dr. Brian Self DC explain the procedure of getting the individual onto a DOC decompression machine.
[00:26:39] Dr. Christian DC: Quick question. You mentioned briefly the size of the patients and how heavy they are. We have found that with the large patients with big bellies and, like smaller waists, we can’t get them strapped effectively, especially prone; it’s almost like it’s coming down their butt. Is there any way to not create that slippage without cutting off their pelvic circulation?
[00:27:10] Dr. Brian Self DC: So again, on a heavy patient, that’s going to be the drawback as prone is not going to be comfortable, and obviously, you could do supine and take the table all the way down into extension as I showed you. That might be good if you know a couple of things you could do, like your harnessing. And you see this a lot with women who are wearing, like, really slippery silky shirts. You don’t get a lot of slippages. So a lot of times I’ll take my towel. And then drape it over there; it’s the most amount of slippage generally takes place in the thoracic harness. But if you’re treating a problem on a bigger patient, I can see how you could get some of that in the pelvic harness. So but generally, I will take a towel and tuck it around the rib cage, especially if a woman wears a slippery, silky shirt. And then I want to bring this harness over the towel, adding a little bit of grip and a little bit. Also, if it’s tender like if they’re an older lady and have really fragile ribs, that might add just a little bit of comfort; subsequently, you could. And I’ve only done this on a few patients, Dr. Christian, but you could take another towel. And you could drape it over their pelvis. And then bring this around that might help, you know, if they’re not, especially if they’re not wearing jeans, jeans usually make it pretty effective. But even just a towel between the fabric and the harness can help. I’ve had patients that, you know, older people, when you put this on, especially like the buckle from the seat belt, it pinches on their hips or the bone. You know, I’ve taken pads, you know, the towel would be my priority. I’ve taken pads and stuffed them in there, like over the hips or wherever they tend to get, or it puts pressure on. You can put at some, you know, you could take something soft and comfortable and slide it in there as well, that that might help as far as if the harnesses are slipping on the patient.
[00:29:48] Dr. Christian DC: If that person we were doing is doing a flexion, not an extension, should I just put them supine to get a better pull?
[00:29:58] Dr. Brian Self DC: Yeah. Suppose you’re in flexion, and it is better than you would want to go supine because they’re going to be a more flexion; if that’s not working, then I would try prone inflection because it is the one thing that can be the most dramatic game-changer of all the parameters. And I know you probably heard this story about Dr. Tom Shack, but he had done hundreds of visits to the treatment table. He owned one, and I think it was either his office or his house. And he used that hundreds and hundreds of times, but only did it supine. And he said, you know, he felt like it kind of helped. But, you know, after hundreds and hundreds of treatments should have been a lot more effective. And then I got him started prone on the DOC table. And, of course, he liked, doubled the parameters that I told him to do. You guys don’t tell him I told you this, but he got way too aggressive and made him so much worse. And he was like; You can come to pick this table up because I can’t even get out of bed. And I said, Well, what parameters are you doing? And he was like, That’s nothing like what I told you to do. So when he did back it off, doing the prone dramatically made a much more significant difference than supine, even though he was a less force and less time than he was doing supine on the Triton table. He was able to get away with even less force and less time prone because of the dramatic difference it had on his discs in whatever way it was addressing that. So if I’ve tried just about everything and nothing’s seemed to be a big difference, just switching them simply to prone can have a dramatic effect. And a lot of times, it’s not even comfortable while the patients are like this is not comfortable at all. But the results start coming so much faster than they’ll tolerate it. But know that being prone is not a comfortable position, but it can be much more effective. And you can get away with a lot less force prone. So, Dr. Christian, maybe if you like prone and you feel like that’s going to be a good one, if you’re getting some slippage with the harnesses, try less force and see if that helps with the slippage as well because you can get away with less force and get the same results because of the prone versus the supine.
[00:32:36] Dr. Alex Jimenez DC: How long do you wait before you go prone, so if we’re starting somebody supine, you’re like, Man, you commented that I’d tried all these things. Well, what are those other things that you’ve tried? And then determined it’s like, All right, we got to flip them over. We have to go prone.
[00:32:49] Dr. Brian Self DC: I’d say probably by the end of the second week. If I haven’t seen any results, I will get much more aggressive. The first week is just trying to get their body used to the treatments, so I don’t usually switch up anything the first week other than increasing one cycle per visit. And so, after the first week, I’m just trying to get their body used to it. Then the second week, I’m starting to add some different parameters to see if any of those will make a difference. So every day, you’re going to treat for the first two weeks. So I almost always start my patients on a Monday, maybe Tuesday at the latest. Maybe Wednesday. I’m not going to start a patient on a Thursday or Friday because if you set them back a lot of times. So like, if you start a patient on a Thursday and you make them worse and then the Friday, you make them worse. Now they have two days of being in that pain till you can see them again, and you lost all the ground you made. So I’m generally starting on a Monday or Tuesday, ideally on Monday. They’re going to treat every day for that first week. All I’m going to do is go up one cycle per visit for that first week. Then the second week, I might add some flexion. I might add some extensions. I might add some lateral flexion or lateral flexion with rotation. I might experiment with the forces and the times. And then, by the end of the second week, if they haven’t seen any results or feel ready for prone, I’m going to flip them over prone, starting probably in week three, the first visit a week three. Now you’re going to go every day for two weeks or until they’re at least 50 percent improved. So in that rare case that you get to the third week and they’re not 50 percent improved, keep going every day until they’re at least 50 percent approved; then, at that point, you can go three times a week for two weeks and then two times a week for two weeks.
[00:35:02] Dr. Alex Jimenez DC: Cool beans.
[00:35:05] Dr. Brian Self DC: To review quickly on prone, everything will be the same about supine, and let’s just quickly review that to make sure what you’re looking for. So you’re looking for this red line to be right at the bottom of this thoracic cushion on everybody, regardless of how tall or short they are. That red line is going at the thoracic cushion. This harness moves up or down. The thoracic harness moves up or down, depending on how tall the patient is. So your shortest patient, you’re five foot zero female. Those two red tabs are going to be touching each other. So this thoracic will slide down until those two tethers zero-gap there. That’s going to be the shortest patient that you treat. And then five foot four to about five foot 11 is going to be about two to three-inch gap there with again with the thoracic harness moving and then six foot two legs six foot seven. It’s going to be a four to five-inch gap there. OK. What this is equal to is the top of the iliac crest, which always goes at the top of this pelvic harness or the red line is about the ASIS, so that is always on every patient that’s going to be standard regardless of whether they’re supine or prone or taller, shorter, heavier. This red line goes at the bottom of the thoracic cushion. There is always that the red line or the top of the iliac crest is at the top of the pelvic harness. OK. And then what you’re aiming for here is for the harness to come for the lowest rib to be right in the center of this harness. So when you’re bringing this around, you’re going to bring it around and down. So we want our very lowest rib to be right in the center. So half of the harness is above the lowest rib, half of the harness just below the lowest rib. OK, that’s stuck around that rib to prevent the patient from sliding down as we pull. OK. So you know that you did it halfway, correct? If this makes an X pattern, OK, so when you come around and down, this should look like an X, and this lowest rib should be right in the center of that harness. And so, again, the distance between these two harnesses is equal to the distance from the top of the iliac crest to the lowest rib. Now keep in mind that because women have higher hips and a higher iliac crest, this base here will be a little bit shorter on a woman than a similar height on a male, so if you have a five-foot-eight female versus a five foot eight male, the five-foot-eight females that are going to be a little bit higher. And so, keep that in mind as well. But when you’re doing prone, all you’re going to do is take your armrests out of the supine slot, and nobody ever figures these out, but you’re going to take this out of the supine. You’re going to turn it around one hundred and eighty degrees and put it on the opposite side of the table in the lower slot facing forward like a chiropractic table. And so the that’ll give the patient while they’re lying prone to put their arms on, and then I usually get a massage face pillow, put it over the thoracic harness so that they can comfortably put their head straight, just a U-shaped massage pillow is fine on that. And then this is going to be flexed down a little bit. So their neck is not extended. And then so they would be laying prone. But all of this is the same, regardless of whether the patient is supine or prone. All of that’s going to be the same landmarks, same philosophy. You’re either trying to create a vacuum effect and reduce a herniated disc or pumping that disc for a degenerative disc with an intermittent short type of cycle. But all that philosophy will be the same, regardless of whether they’re supine or prone.
During The Treatment
Dr. Denay DC and Dr. Brian Self DC explained their experience when going on the DOC decompression machine.
[00:40:18] Dr. Alex Jimenez DC: Good docs, any other questions? Keep on firing them. Dr. Denay, did you get your answers about your back answered last week?
[00:40:28] Dr. Denay DC: I did, yeah.
[00:40:30] Dr. Alex Jimenez DC: Well, yes, shared; it’s good to hear that you’re a patient affected adversely to decom table.
[00:40:38] Dr. Denay DC: Yeah, it was me. I was the first person I couldn’t get off the decom table, so that was good. It was. I did supine, and then Tom and Jack told me to go prone. And then I went back to supine, and I went not prone first but went supine the next day, legacy one, and I couldn’t get off the table.
[00:41:01] Dr. Brian Self DC: Do you remember your parameters regarding how many pounds?
[00:41:08] Dr. Denay DC: So I did one-third of my body weight, weighing 170. So I think it was like 50 pounds. Right? Yeah.
[00:41:18] Dr. Brian Self DC: Do you remember if you did legacy one or?
[00:41:20] Dr. Denay DC: Legacy one.
[00:41:22] Dr. Brian Self DC: For just how many cycles?
[00:41:23] Dr. Denay DC: I was on there like 20 minutes, so two or three cycles. OK. And I felt fine initially, and then there was just a lot of pressure, and I pushed through that, now knowing I don’t ever pull through pain. I should have stopped it right there, and I think it would have been fine. But yeah.
[00:41:42] Dr. Brian Self DC: And that’s a very common mistake. Like I said, I’ve done it hundreds of times. I’ll continue to do it. It’s just it’s either too much force. So I would back it down in your case, back it down to about 40 pounds. I would put it out one cycle and maybe even stop the treatment earlier. See how you do for too much time. If you feel like that, 14 minutes is even too much. And then also, did you do any stretching before you got off the table?
[00:42:19] Dr. Denay DC: Yes, I did. But I think I couldn’t lift my left leg. It was just like pressure and pinch feel. So that’s when I was like I had pulled it up myself, but it was painful to lift it by myself. So then the next day, I reached out to Casey, and he’s like, I don’t know, ask Tom or Jack. Last night, Jack told me to do K1 the next day. So that night, I was super, super sore. I iced all night, and then I did K1 the next day and felt so much better.
[00:42:51] Dr. Brian Self DC: Yeah, and that’s perfectly normal. And it’s hard for patients to understand, but just know that that is perfectly normal. It doesn’t. You see, maybe 15 percent of the time, it will happen like that. You’re going to make a patient worse before they get better. All that means is that you overtreated it. Like I said, either too much force or too much time or a combination of the two. Maybe the patient position had a little to do with it, but back off; everything starts slow and works your way up. If the next treatment you were around like 40 pounds over, like, let’s say, 13 or 14 minutes, see how you do. If you don’t make anything worse, give it a couple of bases, then go up to forty-five pounds over 16 minutes and then maybe 50 pounds over 17 minutes. I would say at least one or two weeks, basically real gently and slowly ramping yourself up. And what you’ll find is that your body will continue to get used to each treatment. And then you’ll hit a visit where most patients hit one visit, where everything just starts to get better from that point on. Now, sometimes that takes a week, sometimes it takes two weeks. Whatever it is, once they hit that visit or start getting better, it all seems to snowball and go downhill from there. But in that interim, you know, you might make somebody a little bit worse before they get better until you figure it out or overtreat them. And that, honestly, I hate to say it, but that’s perfectly OK. You want to avoid it if you can, and you can prevent it with less force and less time and patient positioning.
[00:44:45] Dr. Alex Jimenez DC: I think the communication piece before starting people on decomp is to make sure that you guys are all prepping for those reactions. It’s no different than the adjustment. So as it does occur, if it does happen in that 10 to 15 percent of your patient base, it’s not an alarming piece to the treatment. It’s normal.
[00:45:04] Dr. Brian Self DC: This is expected. And then again, I know you said you did this, Dr. Denay, but make sure that you’re stretching the patient before getting off the table. So while they’re laying there on their back, have them. I have them put their feet flat on the table with their knees up. Just kind of have them rock side to side. You’re just trying to get everything moving again before they go to put all that pressure back on it and then have them bring their knee up to their chest for a minute. Stretch it in. You could add a little bit of overpressure if you wanted. A worst-case scenario is you have them get up and walk it out. They can always walk around the clinic a little bit, and they will slowly start to walk that out. Another thing you could do is you can take your back brace if the disc is super hot and you’re just not sure. You can always take your back brace and put it under. So undo all their harnesses so that everything’s nice and open. And then take your back brace and slide it under while they’re still laying there. You know, just kind of shimmy it under there and then put their back brace on nice and tight and then come off. Often, on a hot desk, you know, it feels fantastic when you’re decompressing it. And then they go to sit up. And all of that pressure comes down, and it can even be worse than before. Having that back brace on there before they get up can sometimes minimize the amount of downward force on that disk, which can help a little bit. And then, you know, stretching them before they get up is huge. And having them walk around the clinic to kind of walk it out. And then we’ve talked about this before, but getting the back braces with the hot and cold packs, keeping them frozen in the office. And so they come in with their unfrozen ice pack when they’re done with the decompression, take your ice out of the freezer, switch it out, so you’re not losing ice packs. Put the ice packs in their back brace. Have them drive home with 20 minutes of ice, then take the ice out and wear their back brace for a minimum of three to four hours after every treatment. The first week I have them wear it all day, every day. I feel like it’s one of the few things that makes a big therapeutic difference in helping to stabilize that disc, helping to remind them not to do anything silly. And so I have them wear their back brace all day, every day for the first week. I think Dr. Cox of Cox’s flexion and distraction. He said he has them wear it more than 48 hours a day for the first, like three days, or even sleep in it. You know, I think three to four hours minimum after every treatment. Six to eight hours on some of your more acute patients can sleep in it if they feel like that helps. So the back bracing, I think, is one of the few things that does for a low cost; it does make a pretty good therapeutic value there.
[00:48:43] Dr. Alex Jimenez DC: OK, docs, any other like prone versus supine moving doctors through? I think he hit that pretty well, but is there any confusion? Or positioning? I think we’re pretty good on that. I guess remaining questions on that topic.
[00:49:03] Dr. Brian Self DC: One thing, if you can’t see what you have in mind, I know going over K one, I sometimes think how to put in the parameters on a computer that can be a little bit confusing sometimes. But what do you have next?
The Recovery Process
Dr. Brian Self DC explains the after-care protocol that all individuals must do after getting treated with spinal decompression.
[00:49:17] Dr. Alex Jimenex DC: I think just noted contraindications. There’s an average presenting patient. So you talked about a grade three forces on spondylosis, just direct contraindications? Yeah.
[00:49:31] Dr. Brian Self DC: Yeah, I mean, there’s a complete list I’ll send you. You know, my philosophy is if you didn’t adjust it, you probably wouldn’t decompress it. So anything, you know, that’s metastasized to the spine, multiple myeloma cancer that’s affected the vertebra, disk infection, an artificial disk, in my opinion, is an absolute contraindication. I think they’re not that great. I think you wouldn’t want to be blamed for a pretty crappy product in the first place. Pathologic aortic aneurysm. You know, there’s a certain amount of millimeters. I can’t remember what is at the top of my head, but any sort of aortic aneurysm, if you wouldn’t adjust it, you probably wouldn’t decompress it. Pregnancy? You know, screws, rods, cages. I have to tell you guys; technically, it is a contraindication. The only thing I can say is that doctors treat them all the time. They focus on the area above or below, you know, from all the surgeons I’ve talked to, they’re going to tell you that you couldn’t pull a rod or a screw loose with 40 pounds of force or 50 pounds of force or 60 pounds of force. But technically, rods and cages are a contraindication. A discectomy is one that many people ask about in a failed discectomy. The research recommends waiting a year after a failed discectomy or laminectomy. There’s going to be a lot of scar tissue in there. The one patient I treated with a failed discectomy was only about six months old. It was just the treatments were just way too sore. It made him way too sore. I was just pulling on that scar tissue that hadn’t fully healed; you know, pulling on relatively fresh surgical tissue did increase his pain enough that he couldn’t finish the treatments? Now, some people have argued that, you know what? A better thing could you do than to apply some gentle, extended access distraction over time on healing scar tissue to get it, align better, get it, and not, you know, not form as much in the first place. And to improve the motion of that scar tissue, I can see that argument. But technically, you’re supposed to wait a year after a failed surgery or a year after a compression fracture if you have a pretty decent compression fracture. It’s recommended to wait at least a year before you treat that.
[00:52:26] Dr. Alex Jimenez DC: What about adjusting? Are you adjusting all patients right out of the gate? I’ll get that question a lot.
[00:52:36] Dr. Brian Self DC: So that’s a philosophical question. And if you ask ten different specialists, you’re probably going to get at least five other answers. My personal opinion is I don’t adjust these; I don’t adjust the area that you’re treating. If you’re treating a lumbar disc, I’m not going to adjust the lumbar for probably four or five weeks. I might do activator, arthostem, pro adjuster, or maybe some drop. But the last thing I’m going to do is put the table on their side. Put them in the flexion and then rotate a disc that was injured by flexing it and rotating it in the first place. Now I might adjust their thoracic adjust their cervical spine. But I’m the only thing I’m doing to that lumbar disc is warming it up, and then I’m decompressing it, and then I’m calming everything down, and then I’m stabilizing it with the back brace and telling the patient for the first three to four weeks, don’t do anything. You know, no exercising, no gardening, vigorous labor, and nothing for the first three to four weeks. Just let it calm down, let it heal. And then, at that point, you can start rehab, start your stretches, start your, you know what, all the good stuff that you guys do. Just don’t do it too soon. I talked to many patients who say I did six months of physical therapy, which made this worse, or I saw no improvement. You have been decompressing it for a week and a half, and I’m 90 percent improved. How could that possibly be? You know, we did because we left it alone. We’re taking all the pressure off of it and letting it heal. In contrast, your physical therapist had you ride the bike, walk on the treadmill, and massage it. And they were just constantly irritating it, not letting it heal because that’s what they get paid to do. You know, they get paid to move it. And so, by stabilizing it and letting it heal and then eventually getting into your rehab, in my opinion, you’re going to see a lot better results in the long term.
Back Braces
Dr. Brian Self DC explains how after individuals go through a spinal decompression treatment, to use a back brace to help support the back.
[00:55:09] Dr. Alex Jimenez DC: Good. All right, Doctor. Any other questions while we still have Dr. Self on the call? Speak up if you do.
[00:55:19] Dr. Melissa DC: I have one. Melissa. If the patient isn’t able or willing to purchase one of the Aspen braces with high-quality results, we should look for any typical things in a back brace to stabilize?
[00:55:35] Dr. Brian Self DC: No, the the the cheapest one. That’s a suitable brace. This one here. I love the Aspen Braces. They’re super high quality. They can be a little bit more expensive. I don’t know why you guys pay for the Aspen ones, but this one is called Back Max. And if you call Back Max and Dr. Tom, you could probably even get you an excellent price on these, I mean, they’re probably like 30 to 35 dollars, and they worked with them to develop some hot and cold packs for these two. And so, if it’s a price thing, I would go with this one. And you got the Aspen was a great quality brace, and I think they probably have some hot and cold pack options with that. But if you’re looking for a cost-effective one, that’s still a good brace. I would say this Backs Max one. Also, before I forget, I ran across this week. This one is made by a company called G.T. Simulators. I like this one because it’s like two times the size of anything else that I found. And what I found with a lot of these older patients is anything that you can make more significant. You know, it’s going to be good, but this one is just cool because you can flex it forward and show them the herniation that shoots out and hits that nerve. And then, you know, we’ll take them through with some animations and say, OK, so if we’re compressing it and making that worse, then if we decompress, if we take all the pressure off of that, what the decompression, what is that going to do to this desk right here? Oh, well, it looks like it will suck it back in. Exactly. So you sit and make it worse. We decompress it and create a vacuum effect. Suck it back in. Oh, OK. This would be a long-term fix versus a pill or a shot. So anyway, I don’t make anything off of those models. I just saw that one, and I like that it was so large and looks like an excellent quality one. I know there are a lot of cheaper ones on eBay. I have most of those that I bought like they just fall apart after three or four months.
[00:58:03] Dr. Alex Jimenez DC: So we’ll be out working, and Dr. Self will be working on that flowchart, and all that will help answer a lot of questions on basically everything we talked about today. Dr. Nick, do you have a question? You muted for a second there. But yeah, I was just going to say those back braces. We’ve been using those that Dr. Self just showed you guys for a while. And they’ll send you a like a display as well. It’s just a cardboard display, but it’s pretty well done, and it’s just another piece to add more eyes and more questions to decompression. So it’s just a place to put them on display those braces, so that’s another good thing, too.
[00:58:39] Dr. Brian Self DC: Yeah. I like those braces because they’re supportive, but they’re breathable and small roll-up. They’re not super; they’re restrictive, but not super restrictive. So when patients are traveling with them or, you know, not wanting this big, bulky brace to carry around everywhere, I mean, you can stick it inside a purse with no issues that patients like them because they can, you know, you could long term once they are feeling better, they can golf and those they can do stuff.
Conclusion
Dr. Brian Self DC gives a recap on the advanced benefits of spinal decompression on individuals that are dealing with low back pain.
[00:59:15] Dr. Melissa DC: I had one last question. I’m sorry. Do you have just a one-page handle of the people who think of a sheet that we can give patients we think are candidates for decomp? Kind of just a summary of the who, what, when, where, and when?
[00:59:35] Dr. Brian Self DC: The marketing materials so that you guys should all have, or if you don’t, we’ll get them all over to you for free. There’s a one-page promotional sheet explaining decompression. And then there’s a four-page brochure that’s either specific for herniation and bulges or a degenerative disc. So we kind of group all of our patients into those two categories because your consultation will be based on either having a degenerative disc or having a hernia, then bolting. So if it’s degenerative, we’re pumping the disc, pushing out the toxins, drawing in the proteome glycans and the oxygen and the nutrients to restore the hydrostatic mechanism to make it taller and move better. Your consultation is completely different if it’s a herniated or a bulging desk. What we’re doing is we’re adding some extended access distraction to create a vacuum effect based on the negative millimeters of mercury of pressure to suck it back in. So the four-page brochure that you guys get, you’re either going to have one for a degenerative disc, or you’re going to have one for a herniated or bulging disc. So that’s also a good one to hand out to patients. And then we have like an 18-page brochure. So really, what it comes down to is the printing costs. So obviously, to print an 18-page booklet, you’re not going to want to hand those out to every patient that comes in the door. So all the patients usually get the one-page flier because obviously, that’s going to be a lot cheaper to print now if it’s the absolute perfect patient and they’re going home to try to explain to their spouse what’s going on. I’m going to give them the 18-page brochure because, you know, it’s probably going to be worth it. Or, if I’m mailing one out to a patient, I might give them the 18-page one. But if they’re relatively qualified and I might give them the four-page one to take home because, you know, that might be, let’s say, a dollar fifty to print versus a one-page one that may cost you, you know, twenty-five cents or whatever, fifty cents if you do it in color and then the 18 page one, if they’re pretty highly qualified. So you guys should have access to all of those. We customize all those for your clinic. If you don’t have them, let me know, and I’ll make sure. Jeff Thomas, my graphic designer, usually sends out a link. He’ll customize everything for your clinic, then send you a link. You click on the link, download those brochures, make sure they’re perfect, and send them off to your printer. But to answer your question. There’s a one-page brochure, there’s a four-page brochure, and then there’s an 18-page brochure.
The spine’s primary function is to make sure that the body is moving, twisting, turning, and bending at any angle without any pain. When the spine gets injured in an accident or a back muscle is pulled, it can cause the spinal discs in the spine to become herniated or develop degenerative disorders like DDD (degenerative disc disease) that can cause a person to be in pain. Other back pain issues that can cause a person to be in pain include sciatica, chronic back pain, leg pain, and the inability to move or stand for long periods. When many individuals suffer from back pain, it can cause them to lose their quality of life and make them feel miserable. Luckily there are ways to treat back pain, and that is through non-surgical decompression therapy. In this article, we will be looking at facet syndrome and its symptoms and how decompression can alleviate pain associated facet syndrome. By referring patients to qualified and skilled providers specializing in spinal decompression therapy. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable 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, please call Dr. Jimenez at 915-850-0900.
What Is Facet Syndrome?
As previous articles mentioned, many individuals have back pain is common worldwide and is one of the most expensive conditions to be treated for. This is due to many individuals straining their back by lifting heavy objects, or their spinal disc is deteriorating due to aging naturally. When the spinal disc starts to lose its function naturally, the outer barrier of the spinal disc begins to become hard. It becomes compressed, losing its soft sponge-like texture, causing the inner walls of the spinal disc to push through the compressed outer layers and become herniated. Facet syndrome is another back pain issue that many individuals tend to suffer due to natural aging. Research studies have stated that facet syndrome is a condition where the spine’s joints start to degenerate and become a source of pain. Facet syndrome can be caused when the joints from the spine begin to get inflamed and degenerate, causing many other back pain disorders to rise like spondylosis, osteoarthritis, and rheumatoid arthritis all over the body.
Other research studies have shown that facet syndrome is the source of chronic spinal pain that can be unilateral or bilateral back pain radiating from one or both buttocks, the sides of the groin, and the thighs, and just stopping at the knees. Facet syndrome can also mimic any excruciating pain that is caused by herniated discs or compressed nerve roots on the spine.
Facet Syndrome Symptoms
Since facet syndrome is the most common cause of low back pain, research studies have shown that local aches often characterize facet syndrome to some degree of stiffness on the spinal joints. The pain from facet syndrome usually ranges from a dull ache to sharp shooting pain that causes the person to be unable to function. Some of the signs and symptoms caused by facet syndrome are similar to other back pains. They occur together and cause overlap, making the diagnosis challenging for health practitioners. The signs and symptoms of facet syndrome usually depend on the severity and involvement of a nearby nerve root which can cause:
Decompression Therapy Effectiveness For Facet Syndrome-Video
The video above shows how the DRX9000 decompression machine treats facet syndrome. Research studies have shown that facet syndrome is caused by degeneration of the spinal joints due to repetitive overuse and everyday activities that cause microinstability and compress the surrounding nerve roots. When this happens, it can cause excruciating back pain to the individual. With the DRX9000 decompression machine, many individuals will begin to feel relief from facet syndrome. As part of spinal decompression therapy, the DRX9000 decompression machine gently stretches the spine to release the compressed spinal discs and allow the beneficial nutrients and oxygen back into the spine. Many individuals with low back pain begin to feel relief by utilizing decompression therapy as part of their wellness journey. If you want to learn more about spinal decompression therapy, this link will explain the benefits of spinal decompression and how it can alleviate low back pain symptoms.
Decompression Therapy For Facet Syndrome
Decompression therapy is utilized for individuals suffering from low back pain and facet syndrome. As research studies have shown, the effectiveness of decompression therapy can help individuals with facet syndrome by improving their mobility and activities of daily living and reducing their pain after treatment. Decompression therapy can also help individuals reposition the herniated discs back into the spine and can cause the spinal joints to increase in height. Other research studies have shown that since facet syndrome is the cause of low back pain, radiculopathy, and neurological deficits due to being close to the adjacent nerve root, decompression therapy can gently stretch the compressed nerve root and cause instant relief to the individual. When individuals combine decompression therapy with physical therapy, it will reduce the chances of painful symptoms coming back.
Conclusion
Therefore, facet syndrome is one of the common causes of low back pain that causes degeneration of the spinal joints. Facet syndrome is also one of the sources of pain and can mimic other painful back symptoms that can overlap, affect the nearest nerve root, and be hard to diagnose. All is not lost as decompression therapy is used as a non-surgical option to relieve back pain issues by gently stretching the spinal disc, joints, and ligaments to relieve the pressure it was under. Decompression therapy has helped reduce many chronic back issues that many individuals have suffered by allowing the nutrients to go back to the spine. With the combination of physical therapy, many individuals who utilize decompression therapy as part of their wellness journey will become pain-free over time.
References
Alexander, Christopher E, et al. “Lumbosacral Facet Syndrome – Statpearls – NCBI Bookshelf.” StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 12 Feb. 2022, www.ncbi.nlm.nih.gov/books/NBK441906/.
Gose, E E, et al. “Vertebral Axial Decompression Therapy for Pain Associated with Herniated or Degenerated Discs or Facet Syndrome: An Outcome Study.” Neurological Research, U.S. National Library of Medicine, Apr. 1998, pubmed.ncbi.nlm.nih.gov/9583577/.
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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.
Conservative Treatment
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.
Surgical Treatment
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.
Epidemiology
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.
Risk Factors
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.
Differential Diagnosis
Degenerative disc disease
Mechanical pain
Myofascial pain leading to sensory disturbances and local or referred pain
Hematoma
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
Tumors
Pelvic endometriosis
Facet hypertrophy
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.
Radiography
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.
Diskography
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.
Conservative Therapy
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.
Surgical Therapy
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.
Novel Therapies
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.
References
Anderson, Paul A. et al. Randomized Controlled Trials Of The Treatment Of Lumbar Disk Herniation: 1983-2007. Journal Of The American Academy Of Orthopaedic Surgeons, vol 16, no. 10, 2008, pp. 566-573. American Academy Of Orthopaedic Surgeons, doi:10.5435/00124635-200810000-00002.
Fraser I (2009) Statistics on hospital-based care in the United States. Agency for Healthcare Research and Quality, Rockville
Ricci, Judith A. et al. Back Pain Exacerbations And Lost Productive Time Costs In United States Workers. Spine, vol 31, no. 26, 2006, pp. 3052-3060. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/01.brs.0000249521.61813.aa.
Fardon, D.F., et al., Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology. Spine J, 2014. 14(11): p. 2525-45.
Costello RF, Beall DP. Nomenclature and standard reporting terminology of intervertebral disk herniation. Magn Reson Imaging Clin N Am. 2007;15 (2): 167-74, v-vi.
Roberts, S. Disc Morphology In Health And Disease. Biochemical Society Transactions, vol 30, no. 5, 2002, pp. A112.4-A112. Portland Press Ltd., doi:10.1042/bst030a112c.
Johnson, W. E. B., and S. Roberts. Human Intervertebral Disc Cell Morphology And Cytoskeletal Composition: A Preliminary Study Of Regional Variations In Health And Disease. Journal Of Anatomy, vol 203, no. 6, 2003, pp. 605-612. Wiley-Blackwell, doi:10.1046/j.1469-7580.2003.00249.x.
Gruenhagen, Thijs. Nutrient Supply And Intervertebral Disc Metabolism. The Journal Of Bone And Joint Surgery (American), vol 88, no. suppl_2, 2006, p. 30. Ovid Technologies (Wolters Kluwer Health), doi:10.2106/jbjs.e.01290.
Mercer, S.R., and G.A. Jull. Morphology Of The Cervical Intervertebral Disc: Implications For Mckenzies Model Of The Disc Derangement Syndrome. Manual Therapy, vol 1, no. 2, 1996, pp. 76-81. Elsevier BV, doi:10.1054/math.1996.0253.
KOELLER, W et al. Biomechanical Properties Of Human Intervertebral Discs Subjected To Axial Dynamic Compression. Spine, vol 9, no. 7, 1984, pp. 725-733. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-198410000-00013.
Lieberman, Isador H. Disc Bulge Bubble: Spine Economics 101. The Spine Journal, vol 4, no. 6, 2004, pp. 609-613. Elsevier BV, doi:10.1016/j.spinee.2004.09.001.
Lappalainen, Anu K et al. Intervertebral Disc Disease In Dachshunds Radiographically Screened For Intervertebral Disc Calcifications. Acta Veterinaria Scandinavica, vol 56, no. 1, 2014, Springer Nature, doi:10.1186/s13028-014-0089-4.
Moazzaz, Payam et al. 80. Positional MRI: A Valuable Tool In The Assessment Of Cervical Disc Bulge. The Spine Journal, vol 7, no. 5, 2007, p. 39S. Elsevier BV, doi:10.1016/j.spinee.2007.07.097.
Vialle, Luis Roberto et al. LUMBAR DISC HERNIATION. Revista Brasileira De Ortopedia (English Edition), vol 45, no. 1, 2010, pp. 17-22. Elsevier BV, doi:10.1016/s2255-4971(15)30211-1.
Mullen, Denis et al. Pathophysiology Of Disk-Related Sciatica. I. Evidence Supporting A Chemical Component. Joint Bone Spine, vol 73, no. 2, 2006, pp. 151-158. Elsevier BV, doi:10.1016/j.jbspin.2005.03.003.
Jacobs, Wilco C. H. et al. Surgical Techniques For Sciatica Due To Herniated Disc, A Systematic Review. European Spine Journal, vol 21, no. 11, 2012, pp. 2232-2251. Springer Nature, doi:10.1007/s00586-012-2422-9.
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Injury Medical Chiropractic Functional Medicine and Spinal Decompression Institute offer progressive technology to treat neck and back-related injuries, conditions, and disorders. We utilize a non-surgical spinal decompression system combined with chiropractic adjustments and therapeutic massage that combats back and neck pain. These combined techniques relieve nerve compression and separate the vertebrae in the back or neck to allow for optimal healing. Individuals suffering from herniated discs, sciatica, spinal stenosis, or pinched nerves can undergo decompression treatment to slow, stop, and reverse back issues.
Spinal Decompression Institute
The spine/back is a complex structure of joints, bones, ligaments, and muscles. Individuals can sprain ligaments, strain muscles, rupture disks, and irritate joints, leading to back issues and pain. Injuries from work, school, automobile accidents, and sports can lead to health issues that can become chronic and cause permanent damage.
Motorized mechanical decompression separates the vertebrae and discs, allowing them to realign and reset properly while increasing circulation, hydration, and oxygenation into the discs to heal fully.
This removes the compression on pinched nerves.
This is spinal retraining so the spine can remember a new healthy position.
What A Session Consists Of
The individual’s doctor, spine specialist, or chiropractor will determine the treatment plan after their in-person physical evaluation and review of imaging scans like X-rays and/or MRI.
Every case is different, but a session typically requires 20-30 minutes.
Treatment plans differ in the number of sessions per week and the number of weeks necessary.
Patients remain clothed during a spinal decompression therapy session and lie on a motorized table.
Depending on the condition or injury, the patient could be in the prone position lying face down or lying supine face up.
A harness is placed around the hips or neck.
The technician/therapist sets up the program.
The table will move slowly back and forth and/or to the sides to provide spinal traction, release the compression, and promote relaxation.
There is no pain during or after the decompression therapy, but the patient will feel their spine stretch.
To avoid any discomfort, the system has emergency stop switches for the patient and the therapist technician.
The switches terminate the treatment immediately if the patient experiences pain or discomfort.
Physiological Well Being
Increases blood circulation and promotes nutrient supply through the spine.
At the Spinal Decompression Institute, we offer total care for complete health and well-being. Our goal is to thoroughly investigate the body’s health and determine the root cause of the pain. A successful spinal decompression program will help identify what led to the problem/s to prevent and avoid a recurrence of symptoms.
DRX9000 Non-Surgical Spinal Decompression System
References
Apfel, Christian C et al. “Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study.” BMC musculoskeletal disorders vol. 11 155. 8 Jul. 2010, doi:10.1186/1471-2474-11-155
Daniel, Dwain M. “Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?.” Chiropractic & osteopathy vol. 15 7. 18 May. 2007, doi:10.1186/1746-1340-15-7
Koçak, Fatmanur Aybala et al. “Comparison of the short-term effects of the conventional motorized traction with non-surgical spinal decompression performed with a DRX9000 device on pain, functionality, depression, and quality of life in patients with low back pain associated with lumbar disc herniation: A single-blind randomized controlled trial.” Turkish Journal of physical medicine and rehabilitation vol. 64,1 17-27. 16 Feb. 2017, doi:10.5606/tftrd.2017.154
Macario, Alex, and Joseph V Pergolizzi. “Systematic literature review of spinal decompression via motorized traction for chronic discogenic low back pain.” Pain practice: the official journal of World Institute of Pain vol. 6,3 (2006): 171-8. doi:10.1111/j.1533-2500.2006.00082.x
The body is a well-tuned machine that makes sure that it moves constantly and functions appropriately. The body is also home to the organ systems, muscle tissues, skeletal joints, and cellular structures, where it’s their job to make sure that the body is working and getting the nutrients that it needs to keep everything working together. When different scenarios start to affect the body, it can cause different types of issues that can not only damage the body but also cause it to be dysfunctional. These scenarios can be done internally or externally to the body and can damage the organs, joints, or even the spine. In this article, we will be looking at what the spine does and what spinal decompression therapy is. By referring patients to qualified and skilled providers specializing in spinal decompression therapy. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable 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, please call Dr. Jimenez at 915-850-0900.
What Does The Spine Do?
The spine is located in the back and makes sure that the body is not falling apart as it is the body’s central support structure. Research studies have shown that as part of the musculoskeletal system since the spine is connected to different parts of the muscle tissues that make sure that the body is moving. The spine’s primary function is to help the body sit, stand, walk, twist, and bend as it is in motion. A healthy spine will have these natural curves that will absorb shocks that the body encounters and protect the spine itself from injury in an S-shaped curve. Other research studies have shown that the spine comprises bone, cartilage, ligaments, nerves, and muscles that play an integral role in how the spine is formed and how it functions. The many different parts that make up the spine include:
When back pain or spinal injury starts to affect the back and the spine, many back issues will begin to affect the spinal health over time. This is due to the spine’s vertebrae and disks wearing down due to age, and that can cause the individual pain. There are ways to lessen the pain from the spine, and that is through spinal decompression therapy.
Walking With Spinal Cord Injury-Video
The spinal cord is made of soft tissues. It encompasses the spine as the spinal cord is a part of the central nervous system. Research studies have shown that spinal cord injury is when there is damage to any part of the spinal cord or damaged nerves that can often cause permanent changes in a person. Some of the symptoms caused by spinal cord injury can be complete, where all the sensory and motor functions are lost below the neck, or incomplete, where a person will have some of the motor and sensory functions below the waist. All is not lost as there is therapy rehabilitation to strengthen the spine and spinal cord from incomplete spinal cord injury, and one of those rehabilitations is spinal decompression therapy.
What Is Spinal Decompression Therapy?
Since the spine provides support to the body, spinal injury or spinal degeneration to the spine can cause excruciating pain to anybody. Around 80% of individuals usually suffer from a back injury. Research studies have shown that when a person is feeling severe pain in the spine, it is due to the compression that puts loads of pressure on the spinal cord or the nerves themselves. The best way to relieve the spinal cord’s stress is through spinal decompression therapy.
Research studies have found that spinal decompression therapy is a non-surgical decompression therapy that involves stretching the spine by using a traction table to relieve back pain or even leg pain that a person is suffering from. Other research studies have stated that spinal decompression therapy can also reduce the pressure on the intervertebral disc by supplying nutrients and oxygen back to the disc. This will cause relief to those pressurized discs as it causes negative pressure on the spine. Once a person receives spinal decompression therapy, they will notice a significant pain reduction in their spine and a higher increase in their range of motion as they become pain-free.
Conclusion
All in all, it is essential to make sure that the spine is healthy. Since the body is a well-tuned machine, it is necessary that the spine is being taken care of. Even though there are many scenarios that the body can get into when a person gets a back injury, it is crucial to recover and go to therapy sessions to relieve the pain, or else it will get worse over time. Spinal decompression therapy is a non-surgical option that many individuals can utilize. It provides a gentle stretch on the spine, causing instant relief to the compressed spinal disc that is causing a person pain. Using spinal decompression as a therapy option can make a person pain-free and get them back on their wellness journey.
References
Choi, Jioun, et al. “Influences of Spinal Decompression Therapy and General Traction Therapy on the Pain, Disability, and Straight Leg Raising of Patients with Intervertebral Disc Herniation.” Journal of Physical Therapy Science, The Society of Physical Therapy Science, Feb. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4339166/.
As a support structure connected to the musculoskeletal system, the spine makes sure that the body stays upright, moves, bends, sits, and twists as the body are in motion. The spine is also in an S-shaped curve encompassing the spinal cord, soft tissues, and cartilage and is protected by these components. When an individual gets injured and suffers from a back injury, the spine can become damaged, and the individual will be in pain. There are some ways to lessen the pain, and one of the ways to reduce back pain is through spinal decompression therapy. In this article, we will be looking at what low back pain is, its symptoms, and how to manage low back pain through spinal decompression therapy. By referring patients to qualified and skilled providers specializing in spinal decompression therapy. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable 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, please call Dr. Jimenez at 915-850-0900.
What Is Low Back Pain?
Approximately 25–60% of individuals who experience low-back pain (LBP) will report a recurrence of pain within as little as one year. Research studies have shown that low back pain is widespread in individuals. It can result from a variety of different injuries, conditions, and diseases from muscle or tendon injury in the back. Lower back pain is the most common cause of work disability in the US, as many individuals are on disability for low back pain for six months. Usually, many individuals will not return to work due to low back pain. The pain can range from mild to severe depending on the injury that a person has endured while also making it impossible for individuals to do their daily tasks because of low back pain. Low back pain is one of the most expensive reasons for work disabilities since it has been estimated that about 2% of individuals in the workforce in the US will be compensated for back injuries yearly.
Since low back pain is common in many individuals, other research studies have found that the lower bottom part of the spine has only five vertebrae, and it does all the heavy lifting that a person does. This part of the area will experience lots of movement and stress that a person is doing, which leads to wear and tear on the lower back and, later on, injuries. Structural abnormalities such as disc degeneration or disc herniation and resultant biochemical effects such as inflammation can be the cause of disc-related pain.
The Symptoms
Research studies have found that depending on how mild or severe low back pain causes in a person, the muscles that encompass the lower back will begin to feel a burning or stabbing sensation of pain that can run down from the lower back down to the legs. Some of the factors that can cause lower back pain can be age since low back pain is common as a person gets older, physical inactivity where there are unused muscles that are weak in the back, excess body weight which puts more stress on the back, and improper lifting which is where a person uses their back instead of their legs. Some of the symptoms that can cause low back pain can progress further into chronic issues include:
When a person suffers from low back pain, the pain symptoms can range from mild to severe as the pain travels from the lower back to the legs. The pain causes the individual to develop wear and tear on their lower back and, if it is not treated, can lead to chronic issues over time. One of the therapeutic options that can relieve their lower back pain is spinal decompression therapy. Research studies have stated that spinal decompression is a non-surgical decompression therapy that involves gentle stretching to the spine using a traction table to relieve back pain.
How To Manage Low Back Pain
Research studies have shown many ways to treat and manage low back pain. Some, if not most lower back pains can get better in a month with some home remedies. Since everybody is different and depending on what kind of back pain they have, some of the ways to manage low back pain include:
Some of these treatments can help ease the symptoms of low back pain and provide relief to many individuals suffering from back pain and help lower the inflammation in the lower back. With these low back treatments, the body will be able to recover, and the individual can continue with their wellness journey by managing their lower back pain.
Spinal Decompression Therapy
Since about 80% of adults have experienced lower back pain at some point, research studies have stated that when a person is dealing with lumbar pain due to a degenerative process and light external injuries to the spine can use spinal decompression therapy as a non-surgical treatment for lower back pain. Spinal decompression therapy can help reduce intervertebral disc pressure by supplying nutrients and oxygen through gentle spine stretching. Other research studies have found that individuals who use spinal decompression therapy for about 6-weeks will experience less stress on affected discs, a vertically expand of the intervertebral space, and restoration of disc height, as effective in reducing chronic low back pain.
Conclusion
Many individuals have suffered from lower back pain and experienced mild to severe symptoms that can cause them to stop their everyday activities. Utilizing non-surgical therapeutic options like spinal decompression therapy can help alleviate the painful symptoms of lower back pain by gently stretching the spine using a traction machine. Spinal decompression therapy can help release the intervertebral disc’s compressed pressure and help restore the disc height on the spine. When many individuals use spinal decompression therapy as part of their treatment, they can feel relief from their lower back pain and continue their wellness journey.
References
Apfel, Christian C, et al. “Restoration of Disk Height through Non-Surgical Spinal Decompression Is Associated with Decreased Discogenic Low Back Pain: A Retrospective Cohort Study.” BMC Musculoskeletal Disorders, BioMed Central, 8 July 2010, www.ncbi.nlm.nih.gov/pmc/articles/PMC2912793/.
Choi, Jioun, et al. “Influences of Spinal Decompression Therapy and General Traction Therapy on the Pain, Disability, and Straight Leg Raising of Patients with Intervertebral Disc Herniation.” Journal of Physical Therapy Science, The Society of Physical Therapy Science, Feb. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4339166/.
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