Understanding The Herniated Disc

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Welcome to the Back Pain Solutions Podcast – Understanding the Herniated Disc

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Introducing The Herniated Disc

The intervertebral disc is an important structure that is present between each vertebral body of the spine. There are 23 discs in total throughout the spine and whilst movement potential at each level is relatively small, the combined potential allows us great freedom to perform many activities. However, it is a structure that must be respected, as it is vulnerable to injury so it is important that we understand it so we can learn how to protect it.

In this episode we discuss the anatomy of the intervertebral disc and the anatomical variations that can be seen between individuals. We identify the 3 major components to the intervertebral disc: the nucleus pulposus, annulus fibrosis, and the end plates, as well as discussing the key actions that we want to avoid in order to protect it. We also highlight how individual variation can dictate potential vulnerability to injury when performing different activities.

Herniated Disc Causes

Each intervertebral disc separates two vertebrae and forms a joint complex. The intervertebral discs vary in shape throughout the spine but also between individuals. For example, in the lumbar spine intervertebral discs are often oval or resemble a kidney bean shape. This shape is important as it can have an influence on the risk of injury.

Each intervertebral disc has an endplate above, and below, the cartilaginous material of the disc, which plays an important role in resisting any pressures placed on the spine. Inside each disc is a nucleus known as the nucleus pulposus which is embryonic tissue. As a result, it is not recognised by the body and is the reason why individuals can suffer so much discomfort when they experience a disc injury as it an acute inflammatory response.

Fluid within the disc, the nucleus, acts as a ball and the upper part of the disc rolls around on the structure to provide movement potential. Surrounding the nucleus are concentric layers of cartilaginous material, which strengthen the disc, and help to contain the nucleus. The layers of cartilaginous material are orientated at an angle of 45 degrees and the fibres within each layer extend across the disc in opposite directions. When compressed from the top these fibres act like guidewires to support the structure.

When the spine is under pressure, outside of its neutral position, such as when twisting we place the disc at risk of injury. A single traumatic event is infrequently the cause of damage but when we repetitively put pressure on the disc outside of the neutral spine that is when injury can occur. The result is a delamination of the fibres of tissue containing the nucleus, which can result in disc herniation as the nuclear material ‘worms’ its way through the layers to the outside. Due to the proximity of the nerve roots, these can often be aggravated by disc herniation with resultant leg pain. If we respect movement, and learn how to keep the spine in neutral, then it’s incredibly resilient to injury.

Even if injury is present, if you learn to keep the spine in neutral then recovery from injury is achievable but the right environment MUST be created to allow this. If repetitive, deleterious, activities continue then aggravation will continue to occur and injury will remain.

Over time it is the gradual, and low volume, loads that often are the cause of injury. However, if we learn the key movements that protect the spine and remove the pain triggers then we have a great capacity for successful recovery.

Show Highlights – The Herniated Disc

The intervertebral disc is difficult to damage if the back is kept in neutral. All efforts should be made to keep the back straight throughout the day, understand the pain triggers and learn key movements to keep herniated disc recovery time to a minimum. Without keeping that back in neutral, and avoiding the aggravating factors then recovery will be protracted.

Interview Transcription for Understanding The Herniated Disc

Ben James 0:00
When we’re young, we move in freedom and confidence with a great resilience to injury. Somewhere along the line, we’ve developed poor habits and become more vulnerable to back pain. Smart, strong features evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better health. So join us as we demystify some of the commonly held beliefs about back pain. and build your confidence, to a stronger back, the smart way.

Welcome back to the smart strong podcast with me Ben James, and my good friend and co host Jacob stain morning, Jacob.

Jacob Steyn 0:34
Morning, Ben.

Ben James 0:36
So to date, we’ve discussed a number of topics around the back and back health and the aim of smart strong with I think it’s fair to say particular focus on the intervertebral disc and disc herniation. So today, we thought we would discuss disc anatomy and put some of the concepts that we’ve talked about and some of the risk factors that we’ve talked about into a bit more perspective for the listeners. So, disc anatomy clearly is plays an important focus on on back health back pain and disc herniations. And understanding how that disc is made or why it’s vulnerable when it’s vulnerable signs and symptoms of disc issues, you know, and what does this mean for you if you’ve had a disc injury or suspected disc injury, and in the long term in terms of training in terms of pain and in terms of rehabilitation, so, to kick us off Jacob, brief description of the intervertebral disc and then let’s discuss in a little bit more detail.

Jacob Steyn 1:40
Right, so it’s a little bit difficult to do it without a picture. So I’m going to ask everybody listening to imagine it in front of you. We will start by looking at what’s called the joint complex. So a joint complex in the spine is with You have two vertebrae on top of each other, stacked on top of each other. And in between these two vertebrae these two bones you have a disc, the vertebral disc. So the disc is actually a very important component to allow the movement between these two bones but not allow them to to lose each other, if you understand what I mean in terms of staying connected to each other, so that the big question here is really how healthy is your disc. Now the disc is made up of a few parts, a few components, and you got to look at the disc. If you look look from the top as a little bit of a kidney, kidney shaped a kidney bean shaped disc, some discs are more in the shape of a kidney, bean and some are a little bit more oval. And that’s just depending on your anatomy.

Ben James 3:04
And,yeah, another important point there just to jump in sorry, Jacob is that, you know that that shape as it were, and that variation in shape between individuals is quite an important factor when we consider the different exercise exercises or, or activities that people want to do, because that lends itself to potential risk or not in different activities. It’s fair to say which we can, you know, come on to in in more detail detail in later episodes, but it is just something to acknowledge that, that variation between individuals and also the impact that may have on certain activities that we perform.

Jacob Steyn 3:47
Yeah, that’s a good point. And I think you’re right, let’s speak about that another time. Because it’s, it’s going to open a whole different, a lot of detail.

Ben James 3:56
Yes, yes. So if we get back to the to the disk

Jacob Steyn 4:00
You, like I said, you have these two main shapes, and then all the variations in between the oval and the kidney bean shaped disc. And then we have, if you take the disc, and you look from the side, so you look front on to the spine and you you look at the disc in that direction. above and below the desk, you have what we call the end plate. And the plate is the connection between the vertebral body, the bony bit, and the actual cartilaginous disc. And that’s very important because this connection needs to be intact, and it needs to be healthy. And let me speak a little bit more about that in a moment. But I’m going to first go through the anatomy. And then if we look at what’s inside the disk inside the disk we have in the center what we call the nucleus, Paul posis. Yeah, nucleus for posters is a you can see it as a bowl of fluid. It’s actually embryonic fluid so it’s very, it’s foreign to the body. So if it would ever leak out the body would get a bit of a shock in terms of recognizing it and then that’s why we often get such a big inflammatory response when we do get a herniated disc where this fluid substance protrudes or escapes from the disk into the into the body. But then this, this fluid actually acts as a bowl and the upper disk will be rolling on top of this bowl. Right as we know that it’s very difficult to compress fluid. So it’s difficult to compress the fluid. It’s easier to compress the actual disk which is on the side of this fluid. Yeah. And then and then if we look more at the the cartilaginous disk, the actual material that the disk is made up all all men From it’s, it’s actually almost like you’re taking layers of paper, and you’re laying on next to each other, going from the inside to the outside. But the interesting thing is that every piece of layer is going in there in the next piece of layers going in a 45 degree angle, from left to left, bottom to top right, and the next layer will go from the right, bottom, bottom to top left, so it’s crossing over at a 90 degree angle. And if you look at it from side on, as the spine is upright, it’s at a 45 degree angle. Yeah, basically, I think without a diagram, it’s difficult to explain but what you have to understand is that every layer of this court cartilaginous tissue is going in a opposite direction. So if it would be compressed from the top, it’s almost like guy wires coming coming under tension. Yeah, that’s what lens, the disk, it’s, it’s its ability to resist pressure, but also the ability to absorb pressure,

Ben James 7:11
Yes. And just jumping in there, when you consider those concentric kind of rings of tissue and that that variability in the direction of the fibers within that tissue. If you then imagine twisting the spine, which we always want to avoid, and there’s a lot more detail to discuss around movement at the hips, etc, etc, as we move through the different podcast episodes. But if you imagine if you were to twist the spine itself, which we always want to avoid, then you can imagine that if you were to twist to the left, some of those fibers are going to contract and they’re going to be under tension, whereas the other ones working in the opposite direction are going to lose and so they’re going to slack and which is why there’s often certainly a risk injury when you’re doing rotational movements if you haven’t got that brace and that abdominal control. So just something interesting to recognize, I think as part of that, which is going to be a core theme, again, that whole neutral spine in and reducing or eliminating movement should we say.

Jacob Steyn 8:19
I just want to add, I just want to add to that, Ben. And I want to say that, you know, and we want to make this clear when we’re talking is specifically and especially when you’re twisting under pressure, so either we are bending, forward twisting, or if you have weight in your hands. And that’s going to take the momentum to one side, when you twist with your shoulders on your hips. And you know that that’s when it becomes dangerous if you have no weight bearing and you’re relatively strong and your discs are healthy. Yep. And going in one direction twisting should be okay. It’s not something we would want you to do a million times a day. Exactly. Little problem, but yeah, and just to make make it clear that that we have to consider this, especially when there’s a problem at the disk. Or if you are working with a specific type of sport, or your job requires you to twist through your back, then we want you to run to us through the hips.

Ben James 9:18
Yeah, absolutely. And I think, you know, coming back to it just before we go into mechanisms of injury, you know, when you look at this disc anatomy, if, if we, again, back to spine health, if we treat it with respect in terms of how we move, it’s incredibly resilient to injury. In fact, a lot of the studies will show that actually producing an injury and damage to the tissue in a research laboratory, for example of a healthy disc. One traumatic episode is actually very, very difficult. It’s very, very challenging to damage that disk on a one off, traumatic incident. Yes, it can happen, but it’s actually very, very Rare because of the design of that material, but what we tend to see is it’s the repetitive movements in the wrong way, that effect in these tissues.

Jacob Steyn 10:16
Yeah, that’s it.

Ben James 10:19
So if you imagine you put in you know, if you imagine putting a load through the desk, you know, a weight or whatever that might be, and you overload that disk, so you overload the tissue tolerance as it were. So the tissue will have a tolerance to stresses and pressure, etc, etc. If you were to overload that in one incidence, yes, you can. You can damage it, but it’s very rare. Or it’s actually when you look at repetitive activities such as bending from the back and lifting something repetitively throughout the day, then that itself is a repetitive strain on the Back. tolerance for that tissue will gradually decline, then you have an injury. Another example of overloading that tissue would be if you sit in all day, you put in a constant tension to those tissues, not that repetitive from lifting but a constant. Again, the tissue tolerance declines, and then you can you can get a risk of injury. So it’s

Jacob Steyn 11:22
Sorry meant to interrupt you, but it’s just to make it clear what you’re referring to, especially to the people listening, he bennis, especially referring to the disk. So we’re not always but in this case, and in most cases, the tissue that is referring to that will get damaged, especially with these sort of activities is the disk. It will slowly get warm and irritated. And yeah, that’s I just wanted to say that,

Ben James 11:52
Yeah. And what you what you actually see again, is is those kind of concentric rings around that that nucleus in the middle of the disk. With that repetitive motion, they start to delaminate. So they start to separate, I guess and that’s when you start to see that nucleus that that central viscous fluid material start to creep through those layers which is what contributes to the classic disc herniation.

Jacob Steyn 12:24
Exactly.

Ben James 12:24
So the the integrity between the the fibers of these lamina of, of cartilage layers that we have in a disk, they the integrity, it loses its integrity and that’s what then says. So, especially if you have a repetitive movement that ends up pushing the fluid in the middle in the same direction, you will end up allowing the, the fluid to be pushed through and in between these fibers. And, you know, from the research, we knows it looks a little bit like a toothpaste like substance and it will creep through the fibers a bit like a worm. Yeah, and and then it will squeeze out like a worm. If it goes that far back towards the back usually and it would usually be off center. So it wouldn’t be exactly the middle of the back there would be more to the one side.

Jacob Steyn 13:26
Yes, yes, I’m back to that.

Ben James 13:30
Talk about movement. If you imagine you’re flexing forward from from your spine and to the left, you can imagine if you if you were to put that pressure on the desk, if you imagine having a model in your hand and you put that pressure imagine where that the direction of where that nucleus wants to go. If you’re bending forward to the left, then you can imagine and see that material being pushed to the back right. So all these kind of movement patterns when you look at the anatomy at disc start to become obvious in terms of the causation of these injuries and the resultant pain because once you get that material, that worm like movement, as Jacob describes, pushing out the back of the disc, that’s when you start to get the potential risk of inflammatory responses. And because of the, the way that the nerves exit the spine, they can irritate the spine, which gives people that classic sciatica, like pain. And, and that’s where we we start to see a lot more problems and a lot more discomfort. But interestingly, if you look at a lot of the models and a lot of the research, if you were to put that pressure on the on the spine in that flexed position, so we’re talking about bending forward, then you’re pushing that material out the back, but interesting, even if injuries there and you can see that if you keep that spine in neutral and apply the same pressure, then that this material that nucleus, often you will see that it doesn’t push out and again, that’s back to the important A movement, particularly when we have these injuries, that if you keep that neutral posture, despite the injury being there, then gradually over time you’re reducing or you’re taking away the causative factor and the causative movements. And what will happen is you’ll gradually get that vascular and nerve structures into the disk. And it’ll grisel and you’ll find that you can overcome that problem.

Jacob Steyn 15:27
Yeah, and I want to say that it may take a little bit of time, yes. Ben says it will grisel it will it will heal it will get better. It will heal if we create the right environment for it to heal. Absolutely. And if you if you still apply the same causes of problem and might be something that you do with your work or sitting in a car, an hour to work and an hour back. And maybe the the what you’re applying to your back is not as bad as before, when you worked in the garden, you had a recession and the garden for a day. But that may hold you back from recovering. So the ideal environment, we want to create this one, one where you do a specific goal orientated exercises well specific to your, your body. And, of course, the arresting exercises, the relaxation exercises where you completely take the pressure off the disk. And if someone would instruct you how to do that properly, you’ll be able to have the disc and the joint complex, the two bones and the disc in between in a very neutral position. And this is the absolute best and most important part of that healing process. And even if you do that for five or 10 minutes, couple of times a day, you’d already notice a massive difference, especially in the pressure you feel at that place in your back.

Ben James 16:53
Yeah, absolutely. And I think you know, just to summarize that there’s a lot of information that the disk is is it is a Brilliant kind of anatomical feat of engineering as it were, in the way it works, and actually is very resilient to injury. But over time, it’s the gradual low volume loads, but repetitively placed on that structure that that lead to decline in tissue health and lead to injury. But by recognizing the patterns of movement that are causing that discomfort, and taking them away, actually, we can manage these problems very, very well, because disc injury and herniation A lot of people say, well, will it go back in? Will it go back in? Will I will I have this problem forever? And the realities are? Well, it depends. If you continue to aggravate that with the activities that have no doubt caused in the first place, then yes, this problem is going to be continued. Continued pain, continued discomfort and you’re going to feel like you’re left with this problem forever. But actually, if you’re just aware of it, whoever those moments So there’s relaxation techniques, as Jacob says, Be aware of that neutral spine, then actually, these structures have a have the capacity to, to heal or or at least grisel and stop that discomfort. But it’s important that we recognize those movements and take those away as the first step to rehabilitation as it were. And I think the other thing that that we should come back on is discuss don’t just herniate I’m going to posteriorly and they they also move up through the endplate and into the vertebral body. That’s when we often see Jacob the that real marked inflammatory response.

Jacob Steyn 18:45
Yeah. Just to add to what Ben said, there, just want to make it clear again, quick for your imagination. picturing the joint complex in front of you, you have the two vertebral bodies on top of each other In between them you have the disc. And as I mentioned, you have the endplate on top of the disc making contact with the vertebral body. You also have one below the disc making contact with the lower vertebral body, the bony bit and, and so yeah so just like Ben said, You know sometimes if you have an impact or you have a weakened endplate maybe it’s already been irritated and you have an impact and then it’s possible for the nucleus the fluid which we mentioned cannot be so easily compressed as the disk as possible then that actually break through the endplate and gets pushed into the vertebral body into the bone.

Ben James 19:47
Yes, and because that material is enclosed within the disc, normally, when that material moves out of that desk, the body doesn’t remember Recognize that material so therefore, that’s what evokes this inflammatory response. And that’s when you often see people walking around rigid, not wanting to, to make any movement of the spine because of the discomfort at that level, and that’s often accompanied, if you do see image and search MRI, you can often see those changes often you can see these what we call schmorls nodes within the vertebral body on on imaging when these endplate fractures occur. And again, it’s about removing those causative factors that, you know, creating that pain that is going to help with ultimate recovery. And I think that’s the most important message for people on on this podcast is that disc problems can certainly be managed, and they can certainly be managed very effectively. But there has to be an onus on the individual to understand those causes. factors and make a conscious effort habitually and daily activities to remove. Remove those those poor movements because otherwise, you’re just compounding the problem you’re, you’re picking the scab as it were, and and not allowing that tissue time to heal. And then gristle and take pain away, you continue the aggravating the problem. And this is what we see from a lot of people that they don’t understand this and in fairness, they don’t get the advice they need to remove the problem in the first place. So you may go and see a practitioner or clinician to get advice, support. They might do some manual therapies, they might give you some exercises to do to as a rehabilitation program. But actually what it starts with is an exact kind of diagnosis and focus on the area of the problem and take away the causative factors that are creating that pain in terms of movement.

Jacob Steyn 21:56
Yeah, exactly. That’s a very good point. And I’m happy that you mentioned that Because, you know, I think people aren’t aware, people think that it has to be the muscle in the back or, you know, the, they’re not quite sure what’s going on there. Even if they feel it, it is in the in the center of the back. So they think it might be my spine or something’s going on there. But people don’t really realize that it’s actually a disc and they don’t understand this process that we just discussed. So I think for a lot of people, if you’re not still not sure, listen to the podcast again, and try and get an overview. Maybe go online and have a look at the joint complex in the spine while you listen to the podcast. And try to understand that quite often. It is your disc that’s irritated and you get that you know, some it depends what’s going on. You might have a very dull, deep, ongoing my back feels tired feeling. You know, in general, that will not be your muscle And quite often, I have patients who ask her what is it? My is it my is it now the bones? Or is it now? A muscle? And my answer is actually always, always the same. It’s never only the muscle, I mean, the muscle only reacts to what the brain tells it to do. So if it’s tight and protective and cramped, then it’s most likely because of the joint that it’s covering, being either inflamed or irritated. And in this case, if a disc is irritated, that’s quite a big signal to the brain and you can get all sorts of reactions there. Yeah, and, and that, yeah, just to make that clear, you know, if if you have that dull, achy feeling, and your therapist or clinician isn’t giving you a clear, a clear diagnosis with the proper testing involved, then you might be an opportunity to look for a different one, but you want clarity on that because if it’s the case You want to take the right steps to make sure that you get back to recovery and not leave that disc to progress into becoming maybe a full blown hernia or degenerated tissue?

Ben James 24:16
Yeah, exactly. Because the you know, moving on from that, and we’ll discuss further anatomy in the next podcast, some of the other structures around that intervertebral spine or unit as it were. But what you often see is patients that do have disc injury, they might overcome that injury, they might listen to advice, if they get some good advice, and then they learn to move properly. But if they don’t, then it’s often the case that we see pain further down the line which can come from other joints becoming aggravated or as a result of that disc injury. So it is really important that we try and be aware of these problems when they occur, and it doesn’t, as we say, you’re not looking for that single traumatic event, a lot of patients will often say, I can’t, I just can’t think what I’ve done to cause this problem. And it’s always that straw that broke the camel’s back. But over time, you’re aggravating these tissues and the tolerance of those tissues declines and the injury occurs. And then after that, you’ll do one thing that could be really innocuous that suddenly bang, that’s what’s that’s what’s certainly causing your pain. And so, you know, it’s, it’s important to be aware of those movements on a daily basis, but they can certainly, certainly be managed effectively. And if you do that, then you should be able to manage that back and and, you know, help yourself to be resilient to have further reinjury in the future. But a lot of that is to take ownership and to make a conscious effort to develop that core strength and those core strength and those movement patterns that are going to really contribute to spine health because without doing so, then you’re doing a disservice to us. You’re back. And if the clinician isn’t giving you that advice, then that’s a disservice to you as a paying customer, you know, because that is fundamental in terms of your rehabilitation and your success in managing a back problem.

Jacob Steyn 26:19
Yep. Very good, man. I think we should maybe leave it there until we come back to.

Ben James 26:25
Yeah, I think you know, it’s it’s a short episode today just talking about that, that intervertebral disk, put in a bit of theory behind it just to educate the listeners, but certainly, as Jacob says, Go and have a have a look online or in a textbook about the desk because it it, it will put it into a lot more perspective to have that visual aid but it as we say, it’s it’s a structure that is hugely resilient to injury. It’s fantastic in terms of creating the movement that we get throughout the spine. But it has to be respected. And if it’s respected, and you respect the way that you move, then your desk will provide a service to you throughout your life. But if you are constantly aggravating that problem, which we see day on day on day, then you will start to get that that deep dull ache, sometimes all that sudden inflammatory pain when we, when there’s tissue tolerances are exceeded. But it can be managed, it can be managed effectively with movement, which is what this podcast is, is all about. It’s just what the business is all about. So be aware that posture when you sit in all day, give yourself breaks. And then with doing that, you’re really helping to, to manage your back health. And as we move forward into the next podcast, we’ll just we’ll revisit some of these points. We’ll talk about some of the other structures that can be affected with back pain, some of the signs and symptoms and how we, how we manage that pain and discomfort. So Jacob, thanks again. Thanks, listeners for listening in. And we’ll see you next time.

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