Low Back Pain – Emphasis on Disc Injuries (The Anatomy Series)


Transcription of the video is below:

Hey guys, this is Dr. Nima physical therapist with Pro+Kinetics Physical Therapy and Performance, and we are back with another Anatomy and Pathology series. And this time, it’s probably going to be the most important topic and one that you know a lot of people might be asking about, and we’re gonna cover the lumbar disc pathology.

It’s probably the most common injury in physical therapy, in general, not necessarily the disc, but just low back pain in general. We want to get more specific and dive a little deeper into the disc pathologies since in our case, that seems to be more common because we are working with a lot of people that are active, that are lifting a lot of weights or they play sports, whether it’s professionally or recreationally. I’m just going to go ahead and add some layers here so we can get an idea of what’s going on with disc. Just to kind of kick it off, I’ll explain what the disc is all about, and it’s basically this fibrous thick layer or a bunch of layers, that makes up this disc shape, that helps absorb forces that are put through the spine, and also allows for a little bit of range of motion.

Anytime you’re moving or bending, it absorbs some of the shock, and helps distribute that load throughout the spine to help your body move. A portion of that disc also acts to provide stability to the spine and the spinal column as well. I’m just going to go ahead and peel back this ligamentous layer here. You’ll see right in between, those are our disks. And this outer layer, it’s called the annulus fibrosus. That outer layer is what gives us that kind of thick, supportive structure. Inside of that is where the disc is going to sit, which is kind of hard to see in the app, so I won’t dive a little deeper there. We’ll kind of move forward from here, and I’ll pull that ligamentous layer back, because it’s important, and that’s kind of what we’re going to touch on next.

That ligamentous layer, I mean, you have so many of them, if you take a look here, almost going to spin this guy around, you’ll see the disc highlighted in green right over here is protected by this anterior longitudinal ligament. Then we’ll kind of swing around here, highlight the disk again, and you’ll see all these ligaments that are protecting the spine. We’ve got this ligament right here, that’s the interspinous, and that runs through each spinous process all the way through the whole spine. You’ve got all the capsular type of ligaments that basically meet at the joint level between the spine. You’ve got the ones in between the transverse processes, and that’s the inner transverse ligament.

And then, we get down to the SI joint, which is a whole another area, but that is the sacral iliac joint where your pelvis meets the lower part of your spine, which is the sacrum or, as people may know, it’s the tailbone, but it’s still part of your spine. We won’t dive deeper there, but you can also see like the ligamentous structures that run up and down, across in this big one right in the back right here, so we’ll get to that in a later video.

But, back to the disc here and I’ll highlight it again, you can see that the disc is basically in the back kind of exposed, very protected in the front. So essentially, you never will see an anterior disc injury, although it can happen it’s rare, but mostly it’s either going to be lateral which is off to the side, or posterior which is coming through the back.

This area is commonly injured because the amount of forces that can be placed on the spine can be pretty high in these forces occurred during movements including like lifting heavier items off of the floor, lifting weight overhead, rotating quickly through the spine and not using your hips as much or leaning over at an awkward angle, kind of twist it up a little bit through the back and then trying to stand up quickly or maybe lift something in that awkward angle. These injuries can include disc bulges, or different levels of herniations from a slight protrusion to what’s called an extrusion, which is a displacement of the disc material beyond the space where the disc is actually sitting. Those can be pretty extreme, and we won’t dive super deep into extrusions because we I guess in percentage wise, I would say a large percentage of what we see are maybe lighter bulges or medium sized bulges.

Common complaints of disc issues include pain with sitting for longer periods of time if someone is working on the computer, but may or may not decrease when standing up or walking, bending forward, pain with sneezing, coughing or bearing down and then radiating numbness or tingling, or even burning into the glute hamstring. But symptoms that also go down into the calf and foot. When we hear that we think more of a disc related issue compared to something else. If these disc injuries get more severe, you could potentially have a loss of sensation or strength and typically, these cases are the ones that don’t seek out any early intervention, including physical therapy to address these symptoms.

It’s common for disc injury to show up on an MRI. However, there’s a large percentage of healthy individuals that get imaging done, and end up showing disc issues on their images, when they actually don’t present with any symptoms at all. Just because the MRI shows that there’s a disc issue doesn’t necessarily mean that it’s the source of your pain. Usually, it’s secondary to something else that caused the disc issue in the first place.

You know, one of the things can be what I mentioned above, which, if there’s an awkward twist, or you’re lifting something heavy, could be a postural related issue, and a lack of stability or strength of the hip and core muscles could be a loss of flexibility or mobility in the hips, and specifically the hip flexors. I’ve mentioned this in an earlier video, but we’ll kind of talk about some of these here. I’ll pull forward these hip muscles. You got the hip flexors, one of them being the psoas the other one being iliacus, which they cross the pelvis and they meet at the hip right here. Then you’ve of course, got the rectus femoris, which sits on the front part of the hip itself. That sits on the front of the hip joint, and I’ll just isolate it here for you so you get a better view. You can see that there. Then the other thing could be that it could potentially be a nerve entrapment. This is pretty common in disk issues where people will say that you got some numbness and tingling, as I mentioned above, or, you know, a little bit of burning or pain down the leg. These radicular or radiating symptoms could actually be coming from the disk infringing upon the integrity of the nerve. Or it could actually be a nerve entrapment along the way, and may not actually be the disc in the nerve.

But it’s the disc issue, again, as I mentioned, is secondary to something else along the way that’s causing these symptoms and, and that’s what we do as physical therapist is we will dive in a little deeper to the issue, and we’ll do some test, and we’ll look at your posture, and we’ll look at your movement, and we’ll try to reproduce some of the symptoms and do some mobility type testing and kind of put the pieces together and really try to isolate to see if it’s a true disc pathology, or if it’s something else causing your symptoms. I just pulled up the nervous system here, so you can see pretty significant in terms of all the different neural connections that are going throughout the body. It’s pretty hard to directly isolate exactly what nerve but most of the time we’re able to and it’s because it usually presents in a specific way. That will be explained to you during your initial evaluation.

Just as an example, I’m going to dive all the way into the spine here, and we’re going to take it, take a look at this fourth lumbar nerve root. You can kind of see where the fourth nerve root sits, you know, isolate it here and see how it exits below. What’s happening is you have, this is the L five vertebrae. Here we go, L5, L4. Usually if there’s a disc issue they talk about, it’s the L4, L5 disc in that will usually affect the L for nerve root. You can see that kind of that nerve root exiting just below L4 right there. If the L4 nerve root is affected, you can get some of the symptoms down the lower part of the leg. You may get some sciatic type of symptoms where you get it in your glute into the hamstring, maybe some of the inner thigh.

The nerve distribution can be pretty complex, but in the grand scheme the idea is that if you are having nerve symptoms, then we would be looking to see if it’s a potential disc injury. And you know, one thing that may actually not be well known is that the disc has a pretty good capacity to heal. So regular and appropriate exercise, which is the key here, in the appropriate part and the appropriate progression would come from us as physical therapists. Mobility work, core stability, and just general lumbo pelvic strengthening, which is the lumbar and the pelvis as a whole and all the muscles in the area, can significantly improve these discs symptoms.

At Pro+Kinetix we perform a full body diagnostic This includes an extensive evaluation of the problematic area, manual therapy techniques to help relieve your symptoms, and of course, an exercise routine which is the ultimate goal to help maintain relief, improve your mobility, and strengthen your weak muscles to prevent the problem from returning. Thanks again guys, and we’ll catch you next time.

Oakland, CA Pain Management Clinic

Dr. Ben Bagge

Pro+Kinetix Physical Therapy & Performance

"We Help Active Adults & Athletes Get Back To Workouts and Sports They Enjoy without surgery, stopping activities they love, or relying on pain medicine."
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