Lumbar Disc Bulge

Disk lies between upper and lower vertebral body. Disk functions as a shock absorber during walking, jogging and any movements of vertebral column. Back pain originates from disc, nerve, muscle, ligaments, bones, and facet joints. Disc bulge is the most common cause of low backache and leg pain in all age group. Small disc bulge is often asymptomatic. Disc may bulge within foramina or spinal canal. Inner soft and thick gelatinous substance of disc is known as Nucleus Pulposus. Outer concentric tough fibrous tissue, which covers Nucleus Pulposus is known as Outer Fibrous Annulus (see Figure 1). Disc bulge is a projection into spinal canal or foramina of soft gelatinous nucleus pulposus with intact fibrous annulus covering of the disc.

Bulge Disk

Lumbar foramina is a lateral bony tunnel meant to pass the spinal nerve and lumbar spinal canal accommodates lower end of spinal cord and quada equina (see Figure 2). Quada equina is a bundle of multiple nerves below second lumbar vertebrae. Moderate to large sized disc, when bulge into foramina, causes pinch or irritation of spinal nerve (see Figure 1). Patient may be asymptomatic if bulge is small and does not cause any pinch or irritation to spinal nerve. Spinal canal has wide diameter and space. Large disc bulge in to spinal canal may result in pinch or irritation of quada equina (nerves in spinal canal) nerves. Large disc bulge into spinal canal causes spinal stenosis (see Figure 3). Small or intermediate sized bulged disc into spinal canal is often asymptomatic.

Bulge Lumbar Disc pinching spinal nerve

Majority of back pain caused by small disc bulge are self-limiting. Small bulged discs is often not seen in X-ray or MRI as significant abnormality. Chronic back pain caused by bulged disc following injuries has major impact on work productivity. The decline in work productivity is observed secondary to sick leave, restricted work and secondary gain since injury.

Causes of Lumbar Disc Bulge

Injuries Causing Lumbar Disc Bulge

  • Auto or Car Accident- Severe trauma, such as a car accident.
  • Weight Lifting- Improper lifting techniques.
  • Work Accident- Repetitive lifting, bending, standing, and driving.
  • Contact Sports- Participation in contact sports.

Watch 3D Video of Cervical Radiculopathy, Disc Bulge, Herniation:

Diseases Causing Lumbar Disc Bulge:

  • Disc Degeneration- Disk bulge is seen as a normal aging process in older patients suffering with osteoarthritis.
  • Family History- Family history of disc disease is often seen in patients suffering with disc bulge.

Chronic Smoking-

Chronic smoking is associated with disc bulge secondary to weak annulus fibrosis.

Symptoms and Signs Caused By Lumbar Disc Bulge

Lumbar Disc Bulge Symptoms-

General Symptoms

  • Insomnia- Secondary to pain.
  • Weight Loss- Secondary to chronic pain and loss of appetite. Loss of appetite is observed in patients suffering with back pain secondary to cancer and spinal stenosis.

Back Pain-

  • Discogenic Pain- Lower back discogenic pain felt over L1 to L5 lumbar dermatome of lower back.

Lower Back Discogenic Pain

Lumbar Radicular Pain-

  • Character of Pain- Sharp and piercing pain.
  • Pain Provoked By - Standing, Bending, Twisting, Coughing and Sneezing.
  • Time and Intensity of Pain- Pain is worst at night
  • Pain Radiates to Lower Leg- Along the dermatome of pinched nerve L1, L2, L3, L4, L5 or S1.
  • Dermatomal Pain Caused By Lumbar Pinch Nerve
    • L1 Pinch Nerve- Pain is spread over inguinal dermatome.
    • L2 Pinch Nerve- Pain is felt over anterior mid thigh and lateral thigh.
    • L3 Pinch Nerve- Pain is felt over inner thigh and anterior lower thigh.
    • L4 Pinch Nerve- Pain is over lower leg mostly on inside of the leg on anterior and posterior side.
    • L5 Pinch Nerve- Pain is felt over anterior lateral side of lower leg and dorsal skin of feet of middle three toes.
    • S1 Pinch Nerve- Pain is felt over lateral side of feet.
    • S2 Pinch Nerve- Pain is felt over back of the thigh and back of upper 2/3rd of lower leg.

Dermatomal Pain

Tingling-

Tingling is spread along the dermatome of L1 to S2 nerve as described for radicular pain

Numbness-

Numbness is spread along the dermatome of L1 to S2 nerve as described for radicular pain

Signs of Lumbar Disc Bulge

Paravertebral Muscle Spasm

  • Paravertebral muscle spasm is observed between L1 and L5 lumbar vertebrae.
  • Muscle spasm is often continuous and causes severe pain secondary to muscle fatigue and lactic acid accumulation in muscles.

Muscle Weakness in Lower Leg

  • Motor Nerve Ischemia- Severe pressure within intervertebral foramina of lumbar spinal nerve (pinch) causes ischemic (lack of blood supply) changes in motor nerve resulting in weakness of lower leg.
  • Vertebral Column Movements- Flexion, extension, abduction and adduction of lower extremity become weak depending on lesion of level of lumbar spinal nerve.
  • Change of Position- Difficult to get in and out of sitting and lying down position.
  • Lumbar Lesions-
    • L1 Pinch Nerve- Causes weakness of hip flexion.
    • L2 Pinch Nerve - Causes weakness of hip flexion.
    • L3 Pinch Nerve - Causes weakness of hip flexion and knee extension.
    • L4 Pinch Nerve - Unable to extend knee and dorsiflexion at ankle.
    • L5 Pinch Nerve - Unable to perform hallux extension, planter extension, unable to raise big toe upward.
    • S1 Pinch Nerve- Causes weakness in knee extension.

Diminished Knee and Ankle Joint Reflexes

  • Knee Reflex- L2 and L3 Nerve damage causes abnormal knee joint reflex.
  • Ankle Reflex (tendo-achillis reflex)- diminished or absent when L4-5 and S1 nerve is damaged.

Muscle Atrophy

  • Loss of muscle mass is seen on the side of bulged disc disease
  • Muscle atrophy or thinning is associated with weakness in leg.

Investigations to Diagnose Lumbar Disk Bulge

  • MRI Examination- Reliable investigation to diagnose small and large sized disc bulge.
  • Sedimentation Rate-
    • Normal in patients with history of bulge disc.
    • Increase in patients with history of epidural abscess or cancer causing pinch nerve pain.
  • C-reactive Protein-
    • Normal in patients with history of bulged disc.
    • Increased in patients with history of Rheumatoid or Psoriatic Arthritis.
  • White Blood Cell Counts-
    • Normal in patients with history of bulged disc.
    • Increased in patient with history of epidural abscess, osteomyelitis or infections.
  • X-Ray-
    • Normal in patients with history of bulged disc.
    • Abnormal X-Ray finding are observed in degenerative disk disease and spondylolisthesis.
  • CAT Scan- Small disc bulge may not be seen with CAT scan, moderate to large disc bulge are seen
  • Myelogram-
    • Myelogram was a most frequent study performed in the past prior to back surgery.
    • Myelogram is being conducted less often as MRI studies become more frequent.
    • Myelogram is an X-ray study in which a radio-opaque dye is injected directly into the spinal canal.
    • Myelogram provides more reliable information of lumbar disc bulge than plain Xray.
  • EMG- Electromyography- Electromyography studies are performed to evaluate the nerve damage and radiculopathy.
  • Bone Scan- Bone scan is normal unless patient has osteoporosis or osteoarthritis with bulge disc. Bone scan measures calcium concentration in bones and helps in diagnosis of bone tumor, compression fracture, and osteoporosis.
  • Bone Densitometry- The study of bone density is normal unless patient has Osteoporosis.

Treatment for Lumbar Disc Bulge

Medications to Treat Lumbar Disc Bulge

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • Analgesics- Prescribed for mild to moderate pain.
  • Anti-inflammatory Medications- Prescribed for spinal nerve inflammation caused by irritation and pinched spinal nerve. NSAIDs prevents worsening of inflammation.NSAIDs- Aspirin, Ibuprofen (Motrin, Advil) and Naproxen (Aleve).

Tramadol

  • Analgesics-Prescribed for chronic pain not responding to NSAIDs
    Also known as Ultram, Ultracet, Ryzolt and Conzip in USA, Ralivia in Canada.

Opioids

  • Analgesics-
    • Prescribed for chronic pain not responding to NSAIDs or Tramadol.
    • Opioids are beneficial in treating chronic intractable pain.
    • Opioids if used with caution helps to maintain near normal indoor and outdoors activities.
  • Short Acting Opioids- Prescribed for breakthrough pain.
  • Long Acting Opioids- Prescribed for long-term analgesics.

Muscle Relaxant-

  • Mechanism of Action-
    • Stimulates Locus Ceruleus in Brain Stem- Muscle relaxants stimulates locus ceruleus and causes to increase release of norepinephrine in spinal cord. Norepinephrine inhibits alpha motor neuron and leads to relief of spasm in skeletal muscles.
    • Blocks Reuptake of Norepinephrine- Flexeril like amitriptyline blocks reuptake of norepinephrine. It is structurally related to tricyclic antidepressants such as an amitriptyline. Norepinephrine inhibits alpha motor neuron which leads to relief of spasm in skeletal muscles.
  • Most Commonly Used Muscle Relaxants
    • Cyclobenzaprine (Flexeril)
    • Soma
    • Skelaxin
    • Robaxin

Antidepressant Analgesics-

  • Analgesic Action-
    • Effective as an analgesic in treatment of chronic neuropathic pain.
    • Prescribed as an analgesic if NSAIDs, Tramadol or opioid side effects are intolerable.
  • Neuropathic Pain Associated With Depression- Used as analgesics and antidepressants.
  • Most Commonly Prescribed Antidepressant Analgesics-
    • Duloxetine
    • Milnacipran
    • Tricyclic Antidepressants (Elavil)

Anti-Anxiety Medications

  • Benzodiazepam-
    • Anti-anxiety medications are prescribed for anxiety caused by pain.
    • Muscle Spasm- Anti-anxiety medications are prescribed for muscle spasm when associated with anxiety.
    • Sleep Deprivation- Prescribed if patient is suffering from insomnia because of chronic pain and muscle spasm.

Antiepileptic Analgesics-

  • Analgesic Action-
    • Effective as an analgesic in treatment of chronic neuropathic pain.
    • Prescribed as an analgesic if NSAIDs, Tramadol or opioid side effects are intolerable.
  • Neuropathic Pain- Effective in treating neuropathic pain.
  • Most Commonly Prescribed Anti-Epileptics As Analgesics
    • Gabapentin- also known as Neurontin, Gabarone, Fanatrex, Gralise and Nupentin.
    • Pregabalin- also known as Lyrica.

Interventional Pain Therapy-

  • Trans-laminar Epidural Corticosteroid Injection- Epidural corticosteroid injection helps to treat inflammation of the disc and nerve.
  • Caudal Corticosteroid Injection- Caudal epidural injection is an alternative choice of technique of injecting corticosteroid in epidural space.
  • Trans-foraminal Epidural Injection- Trans-foraminal epidural injection is more specific targeted cortisone injection at the bulged disc and irritated nerve.

Manual Therapy to Treat Lumbar Disk Bulge

  • Chiropractic Treatment For Lumbar Disk Bulge
    • Spinal manipulation benefits to treat small and intermediate sized bulged disc.
    • It prevents invasive treatment like Interventional Pain Therapy and Surgery if pain relief is satisfactory.
    • There are very few literatures that support benefits of Chiropractic Treatment.
  • Osteopathic Manipulation For Lumbar Disk Bulge
    • Beneficial during the first month of symptoms.
    • Literature and Studies on this topic have produced conflicting results.
  • Massage Therapy For Lumbar Disk Bulge
    • Massage therapy helps to relieve pain from superficial and deeper layers of muscles and connective tissue.
    • Massage helps to improve blood supply to muscles as well as relieve muscle spasm.

Physical Therapy for Lumbar Disk Bulge

  • Exercise- Stretching Exercise, Flexibility Exercise
  • Application- Heat, Ice, Ultrasound, Electrical Stimulation Like TENS Unit

Electrical Therapy for Lumbar Disk Bulge

  • TENS (Transcutaneous Electrical Nerve Stimulation)
    • TENS mackshine delivers small electric pulses into the body through electrodes that are placed on the skin.
    • TENS induces production of endorphins.
    • Endorphin block pain signals returning to the brain.

Magnet Therapy for Lumbar Disk Bulge

  • Static Magnetic Field- Magnetic field is created by placement of magnet over certain lower back resulting in pain relief and muscle spasm in few patients.
  • Hypothesis- Magnet improves blood flow in underlying tissue.
  • Surrounding Normal Tissue-It does not affect muscles, tendon or underlying soft tissue.
  • Scientific Research- Benefits and technique of application of magnet over lower back is not supported by any research study.

Surgery for Lumbar Disk Bulge

  • Nerve Decompression Surgery- This Surgery is performed to relieve pressure over the nerve
    • Micro Discectomy- Microscopic surgery results in rapid recovery.
    • Percutaneous Disc Removal- Minimum invasive surgery, rapid recovery,
    • Discectomy- Disc removed after skin incision and surgical exposure of disc.
    • Laminectomy- Lamina a bone of vertebrae is removed to eliminate part of the bone forming bony tunnel
  • Spinal Fusion Surgery- Spinal Fusion Surgery is performed when multiple attempts of nerve decompression surgery has failed.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: September 26, 2014

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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