Back Pain: Does it come from the Disc? (Part Two of Three)
In the first part of this three part series we introduced the disc and explained two common misconceptions, namely that discs “slip”, and that discs are “shock absorbers.” This article will review some of the common themes about back pain and how it relates to the disc itself.
The muscles and ligaments around the spinal bones are what generally absorb the stresses of day to day life. Most injuries to the muscle structures occur when already contracting while being stretched. This is very important to remember when considering soft tissue injuries of the lower back and also the other areas of the spine. An example of this would be bending forward to touch your toes. On the way down the muscles of the back are contracting and at the same time they are lengthening (as the joints open and the low back is rounding and lengthening).
The “soft tissues” that surround the disc and the spinal bones are quite numerous and complex. The "Hard Tissue" is the bones. These two descriptive terms really relate to the subject of radiology and x-ray analysis in particular. The best way for doctors of chiropractic, rheumatologists and other specialists to evaluate the hard tissue and the joints in severe cases is to use standard x-rays. The generally accepted “gold standard” for looking at the soft tissues in severe cases is MRI. Please notice how I mentioned severe cases, because all too often these scans are ordered unnecessarily.
Immediately attached to the vertebral bones are the ligaments. Muscles also attach to bones by way of the tendons. Tendons are found at the ends of muscles and serve as the attachment to the bone. Interestingly, most muscle strain injuries occur in the region of the muscle near the ends, where the muscle and tendon join. This is often called the muscle-tendon junction.
Pain originating from the disc itself is possible if there has been degeneration of the disc and there is new growth of nerves on the outer areas of the disc. This is called “Discogenic Pain” and is a source of a great deal of debate and controversy about what it actually is, and especially how to accurately diagnose it. Although it might seem to be the case, “Discogenic” back pain is not the result of a night out dancing! It simply means pain originating from the disc. As we shall see however it is only one of many possible causes of spinal pain.
“Doctor, it feels like muscle pain and not bone pain”
Frequently patients make this statement or similar ones to me in the clinic about their back pains. In actuality spinal pain (particularly lower back pain) is one of the most difficult conditions to diagnose because of the complexity of the region. It is rarely, if EVER, simply “muscle” or “bone.” This is over-simplification and unfortunately a misunderstanding. Back pain is very complex. Different structures and functions can be responsible for pain, each producing a distinctive profile. Pain can arise from the intervertebral disc, either acutely (in the short term) or as result of the degradation associated with chronic (long-term) internal disc disruption. Lumbar pain (lower back pain) can also arise from afflictions within the joint mechanism and from inflammation. Also, patients can experience different symptoms associated with irritation to the nerves, ligaments and muscles. Finally, there can be other causes of back pain such as organ problems or referred pain from other parts of the body that are diseased or malfunctioning. So what is often called "simple back pain" the approach by your doctor (whatever kind you go to) must always take into account all factors and must be comprehensive. Accurate case histories and skilled examinations must be performed. This means you must be patient and not expect a quick fix in most of the cases. The treatment for most spinal pain should be as conservative as possible, depending on the case, and should never involve one type of treatment alone. Exercises specific for the condition should commence as soon as tolerable. I usually prescribe walking or pool exercises when indicated as a great method of physical improvement.
The soft tissues therefore need to be strong, healthy and flexible in order to prevent back pain and dysfunction. However as far as the disc is concerned there are some more interesting facts you should know that follow:
About Disc Degeneration
Disc “degeneration” is actually a natural genetic process of self-destruction. The natural wear and tear type of arthritis (called spondylosis) can affect all of the joints in the spine including the disc, but it is important to realize that this process is not related to trauma or injury! Believe it or not, this is a genetically and biochemically modified process, regardless of what you may read or be told by clinicians. The physical environment has very little or no involvement. This is why some of the patients I see at age 60 have a very healthy looking spine and people in their youth can have terrible ones. Because the disc has a high concentration of water, as the process of degeneration advances, the disc will essentially dehydrate over the years. This actually makes it stiffer as we age and less likely to herniate-and not more! Most people think you are more likely to have a disc problem the older you get- not so! The point to remember is sprains and strains of the back and most of the pains people suffer in the back region are usually not coming from the discs, and the activities of life do not affect the health of the discs at all. To quote the English spine surgeon Dr. Dickson once more:
In our centre, we carry out 2500 MRI scans of the spine each year, and have been unable to find a visible difference in the MRI appearance of a symptomatic from a non-symptomatic degenerated and/or herniated disc. We have not seen a difference in the appearance of a disc hernia, which is demonstrated in a patient who gives a history of injury from a patient who does not give a history of injury. We have not found an abnormality on MRI scanning or any other form of radiological investigation, which allows us to say that a disc hernia was of immediately recent onset, or was several months old, or was less than a-year old or was 2- rather than 3-years old or 3- rather than 4-years old. We have some confidence in stating that a disc hernia is 10- or 15-years old, and we are unable to say if an MRI abnormality of degeneration and/or herniation is symptomatic or will become symptomatic and if so when. We also have patients who have been listed for discectomy on the basis of matching symptoms, signs and MRI appearances who have become symptom-free prior to admission, but still have exactly the same disc prolapse with nerve root compression when the MRI scan has been repeated. [1]
In other words, it is very difficult to truly diagnose the causation and timing of a disc bulge, and the causes of disc-related back pain are truly complex.
In Conclusion:
As we have seen, the discs are very important structures of the human body, and damage to the discs is often misunderstood, difficult to manage, and even more difficult to exactly diagnose. My hope is these articles give you a better understanding of how a thorough examination and correct diagnosis for each individual is vitally important. Next week we will tie it all together and look at how the discs are treated. We will look at which conditions should be treated conservatively vs. those which require surgical consideration. For more information or to inquire about professsional help contact our office in Victoria B.C. Canada at (250)382-4476 or email me by clicking here: info@citychiro.ca
References
[1] Dickson, RA and Butt, WP. The Medico-Legal Back: An Illustrated Guide Cambridge University Press 2004
Yours for Health,
Dr. Eric Backhouse
Back Pain: Does it come from the Disc? (Part Two of Three)
In the first part of this three part series we introduced the disc and explained two common misconceptions, namely that discs “slip”, and that discs are “shock absorbers.” This article will review some of the common themes about back pain and how it relates to the disc itself.
The muscles and ligaments around the spinal bones are what generally absorb the stresses of day to day life. Most injuries to the muscle structures occur when already contracting while being stretched. This is very important to remember when considering soft tissue injuries of the lower back and also the other areas of the spine. An example of this would be bending forward to touch your toes. On the way down the muscles of the back are contracting and at the same time they are lengthening (as the joints open and the low back is rounding and lengthening).
The “soft tissues” that surround the disc and the spinal bones are quite numerous and complex. The "Hard Tissue" is the bones. These two descriptive terms really relate to the subject of radiology and x-ray analysis in particular. The best way for doctors of chiropractic, rheumatologists and other specialists to evaluate the hard tissue and the joints in severe cases is to use standard x-rays. The generally accepted “gold standard” for looking at the soft tissues in severe cases is MRI. Please notice how I mentioned severe cases, because all too often these scans are ordered unnecessarily.
Immediately attached to the vertebral bones are the ligaments. Muscles also attach to bones by way of the tendons. Tendons are found at the ends of muscles and serve as the attachment to the bone. Interestingly, most muscle strain injuries occur in the region of the muscle near the ends, where the muscle and tendon join. This is often called the muscle-tendon junction.
Pain originating from the disc itself is possible if there has been degeneration of the disc and there is new growth of nerves on the outer areas of the disc. This is called “Discogenic Pain” and is a source of a great deal of debate and controversy about what it actually is, and especially how to accurately diagnose it. Although it might seem to be the case, “Discogenic” back pain is not the result of a night out dancing! It simply means pain originating from the disc. As we shall see however it is only one of many possible causes of spinal pain.
“Doctor, it feels like muscle pain and not bone pain”
Frequently patients make this statement or similar ones to me in the clinic about their back pains. In actuality spinal pain (particularly lower back pain) is one of the most difficult conditions to diagnose because of the complexity of the region. It is rarely, if EVER, simply “muscle” or “bone.” This is over-simplification and unfortunately a misunderstanding. Back pain is very complex. Different structures and functions can be responsible for pain, each producing a distinctive profile. Pain can arise from the intervertebral disc, either acutely (in the short term) or as result of the degradation associated with chronic (long-term) internal disc disruption. Lumbar pain (lower back pain) can also arise from afflictions within the joint mechanism and from inflammation. Also, patients can experience different symptoms associated with irritation to the nerves, ligaments and muscles. Finally, there can be other causes of back pain such as organ problems or referred pain from other parts of the body that are diseased or malfunctioning. So what is often called "simple back pain" the approach by your doctor (whatever kind you go to) must always take into account all factors and must be comprehensive. Accurate case histories and skilled examinations must be performed. This means you must be patient and not expect a quick fix in most of the cases. The treatment for most spinal pain should be as conservative as possible, depending on the case, and should never involve one type of treatment alone. Exercises specific for the condition should commence as soon as tolerable. I usually prescribe walking or pool exercises when indicated as a great method of physical improvement.
The soft tissues therefore need to be strong, healthy and flexible in order to prevent back pain and dysfunction. However as far as the disc is concerned there are some more interesting facts you should know that follow:
About Disc Degeneration
Disc “degeneration” is actually a natural genetic process of self-destruction. The natural wear and tear type of arthritis (called spondylosis) can affect all of the joints in the spine including the disc, but it is important to realize that this process is not related to trauma or injury! Believe it or not, this is a genetically and biochemically modified process, regardless of what you may read or be told by clinicians. The physical environment has very little or no involvement. This is why some of the patients I see at age 60 have a very healthy looking spine and people in their youth can have terrible ones. Because the disc has a high concentration of water, as the process of degeneration advances, the disc will essentially dehydrate over the years. This actually makes it stiffer as we age and less likely to herniate-and not more! Most people think you are more likely to have a disc problem the older you get- not so! The point to remember is sprains and strains of the back and most of the pains people suffer in the back region are usually not coming from the discs, and the activities of life do not affect the health of the discs at all. To quote the English spine surgeon Dr. Dickson once more:
In our centre, we carry out 2500 MRI scans of the spine each year, and have been unable to find a visible difference in the MRI appearance of a symptomatic from a non-symptomatic degenerated and/or herniated disc. We have not seen a difference in the appearance of a disc hernia, which is demonstrated in a patient who gives a history of injury from a patient who does not give a history of injury. We have not found an abnormality on MRI scanning or any other form of radiological investigation, which allows us to say that a disc hernia was of immediately recent onset, or was several months old, or was less than a-year old or was 2- rather than 3-years old or 3- rather than 4-years old. We have some confidence in stating that a disc hernia is 10- or 15-years old, and we are unable to say if an MRI abnormality of degeneration and/or herniation is symptomatic or will become symptomatic and if so when. We also have patients who have been listed for discectomy on the basis of matching symptoms, signs and MRI appearances who have become symptom-free prior to admission, but still have exactly the same disc prolapse with nerve root compression when the MRI scan has been repeated. [1]
In other words, it is very difficult to truly diagnose the causation and timing of a disc bulge, and the causes of disc-related back pain are truly complex.
In Conclusion:
As we have seen, the discs are very important structures of the human body, and damage to the discs is often misunderstood, difficult to manage, and even more difficult to exactly diagnose. My hope is these articles give you a better understanding of how a thorough examination and correct diagnosis for each individual is vitally important. Next week we will tie it all together and look at how the discs are treated. We will look at which conditions should be treated conservatively vs. those which require surgical consideration. For more information or to inquire about professsional help contact our office in Victoria B.C. Canada at (250)382-4476 or email me by clicking here: info@citychiro.ca
References
[1] Dickson, RA and Butt, WP. The Medico-Legal Back: An Illustrated Guide Cambridge University Press 2004
Yours for Health,
Dr. Eric Backhouse