In the world of chronic back and neck pain, the narrative often centers around disc bulges and herniations as the notorious culprits. However, delving into the intricacies of these conditions reveals a surprising truth – the evidence supporting them as primary pain generators is sparse.
The Classic Story
Imagine this: you undergo an MRI for persistent back or neck pain, and the results show a disc bulge or herniation. You can take a sigh of relief because you now know what has been causing your immense pain. No need to look any further, we have a fix for this! If you have a good doctor, you will be referred for physical therapy. But after a couple of months if you don't show any progress it's off to the surgeon. Orthopedic surgeons have gotten really good at removing disc herniations, whether through discectomies, where they cut off the herniated portion of the disc, or a spinal fusion where they remove the disc completely and fuse the adjacent vertebra together.
But for a lot of people, surgery doesn't actually improve their pain at all...
The Deceptive Nature of Disc Bulges and Herniations
The evidence supporting disc herniations as primary pain generators is remarkably scarce. Despite this, when detected on an MRI, they are always deemed the culprit of your pain without any further investigation. Because pain feels physical, we assume it has to be from some sort of physical cause, like tissue damage or spinal abnormalities. Treating chronic pain solely based on images and labs is a dangerous game. Rather than addressing the actual cause of pain, focusing on structural abnormalities can lead us down a misleading path prone to more pain and loss of function.
How Do We Know This?
Surprisingly, 64% of adults are walking around with a degree of disc herniation and don't even know it because they aren't in pain! Their disc is pressing on their spinal cord, just like yours is. Yet, no pain... Disc herniations would need to cause pain 100% of the time for us to make the conclusions that we are about them.
Not to mention the phenomenon, and billable medical diagnosis, "failed low back surgery syndrome." Did you know that most common reason for low back surgery is a previously failed low back surgery?! That's right, you are more likely to require low back surgery if you've already had one! Having a previous low back surgery increases the likelihood of requiring another, not because the first surgery failed but because it attempted to correct a problem that didn't existed in the first place. So the surgeon tries again...
So what is causing the pain?
The Unseen Culprits: Bacteria and Glutamate
Disc herniations can trigger pain through less obvious mechanisms, such as bacterial infections, and the spill of glutamate.
These herniations release substantial amounts of glutamate, an excitatory neurotransmitter that irritates nerves, activates pain receptors, and amplifies the pain signals to the brain. Moreover, about 40% of disc herniations harbor pathogenic bacteria, especially the anaerobic bacterium Cutibacterium acnes, causing inflammation and further contributing to the pain.
These are very treatable, but not with surgery.
Disc herniations cause spinal stenosis, but there are other, more common causes. Spinal stenosis is the narrowing of the spinal canal, where your spinal cord travels through your vertebrae. This can cause pain and when it does it is more likely to be due to poor posture than disc herniations.
The human spine evolved in a specific way that enhances movement, stability, and maximizes spinal canal volume. If your spine is not properly aligned, commonly due to poor posture, you consequently diminish the volume of your spinal canal. Leading to stenosis and possible pain over time. We become subjected to poor spinal posture from our daily lives. Desk jobs, computer work, long commutes, lounging on the couch, etc. can all contribute to postural problems. These can be mitigated and reversed with simple at home exercises.
A diagnosis like disc herniation or spinal stenosis can instill fear due to prevalent horror stories you've likely heard. Most people know someone who has had spinal surgery and the results are not as optimistic as we hope. Fear, in turn, can lead to tension, behavioral, and physiological changes that reinforce pain in the brain. Fear-induced chronic pain isn't adequately addressed in the medical community, even though it plays a significant role in pain perception. All this fear is just setting you up for failure no matter what treatment path you decide. Most adults over 30 have some degree of spinal issues, but these imperfections do not necessarily equate to pain. However, once a structural abnormality is identified, the mind can make it a source of chronic pain.
The Ongoing Dilemma of Surgical Complications
A surgical intervention for a disc herniation may seem like a success initially, but months down the line, the pain may persist. This is because the surgery couldn't address the root cause of your pain. Surgery, especially spinal fusions lead to a loss of motion and function. Compensatory movements after surgery can lead to other spinal abnormalities like osteoarthritis, creating a vicious cycle of procedures and complications.
While an abundance of surgical patients don't experience any relief, more than 10% may actually experience worsening pain post-surgery. Operating on a herniated disc can also leave it vulnerable to additional immunological attacks, further complicating the biochemical nature of the pain.
Hydration and Movement: Keys to Disc Herniation Health
Disc herniations often result from the loss of structural integrity. While staying hydrated is crucial, movement is equally vital. Proper hydration and movement act as a dynamic duo for disc health. Movement squeezes out metabolic waste and facilitates water and nutrient absorption, preventing disc herniations from originating, worsening, and becoming persistent sources of pain. While movement may be a source of spinal pain for you, there are certain movements that are safe and beneficial, even if they cause pain, for you. Make sure to speak with your doctor about what movements should be enforced in your daily life!
Before opting for surgery, make sure to exhaust ALL options and recognize that chronic pain is often more biochemical and mental/emotional than purely physical. A comprehensive approach, including mind-body counseling, is essential for effective chronic pain management. Understanding the intricacies of disc herniations is pivotal on our journey toward a pain free life!