ASYMPTOMATIC DISC HERNIATIONS
Fact or Fiction?

PAIN

Asymptomatic Disc Rupture
Image by Mansuper

BOTH HAVE A HERNIATED L5 DISC
(LATERAL VIEW)

NO PAIN

If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.  World's foremost sports surgeon, Dr. James Andrews after doing shoulder MRI's on 31 healthy big-league pitchers visiting him for other reasons, and then finding that 90 percent of them had both cartilage and Rotator Cuff abnormalities.

Like Dr. Andrews in the quote above, many of you have found out the hard way that MRI examinations are not all they're cracked up to be.  Oh; most people already realize that x-rays will not show a Disc Herniation.  But they are typically under the impression that an MRI will show anything and everything that might be wrong with you.  But if you have followed my DAY TO DAY BLOG, you are aware that this is frequently not the case.  

Spend any significant time researching Disc Herniations, you are likely to have heard of "Asymptomatic Disc Herniations".  Buckle your seat belts and hold on to your hats because this is going to start getting interesting.  Depending upon whose research you believe to be the most accurate, between 35% - 75% of the adult American population has Asymptomatic Disc Herniations.  What does this mean?  Only that the majority of U.S. adults are walking around with Disc Bulges / Disc Herniations ----- but have no idea because they do not have back pain or leg pain (SCIATICA). 

FUN FACTS ABOUT DISC HERNIATIONS

  • Herniated Discs are not necessarily painful --- in fact much of the time they are "asymptomatic".
  • The majority of Herniated Discs are asymptomatic (they cause no pain).
  • Surgery is rarely needed to fix most cases of Herniated Disc.
  • SPINAL SURGERY frequently means poor outcomes for Herniated Discs.
  • Herniated Discs do not typically get "more herniated" with time (however, they do end up DEGENERATING).
  • Although the pain may go away after a period of months or years, Herniated Discs do not resolve on their own.
  • Herniated discs cannot be seen with an x-ray. 
  • Herniated Discs can happen without an overt injury.
  • Herniated Discs can happen due to compensation caused by an abnormally rotated pelvis.
  • Medical treatment is not necessary for most herniated discs.
  • Many disc-like conditions are misdiagnosed (i.e. PIRIFORMIS SYNDROME)

In fact, according to the research I am about to show you, if I rounded up 100 people with an average age of 45, with no history of low back pain; and were to do MRI's of the lumbar spine on all of them, the results would be as follows.

  • 35% - 75% would have Disc Bulges
  • Just under 40% would have Disc Protrusions (Disc Herniations contained within the Annulus)
  • Just over one in ten would have Disc Extrusions (Disc Herniations where the Nucleus Pulposes is actually leaking out of the Annulus) --- severe Disc Herniations.

How do I know all this?  Not only have I learned a thing or two over the two plus decades I have been taking care of patients, but there are numerous scientific studies on the subject that encompass nearly six decades.  Let's take a couple of minutes to look at just a few of them.  I want you to note that some of the variations between studies has to do with the fact that there are no hard and fast definitions for terms like Disc Herniation, Disc Bulge, Disc Rupture, etc.  These terms are often used interchangeably with each other and have the potential to create some confusion.


STUDIES ON
ASYMPTOMATIC DISC HERNIATIONS

Asymptomatic Disc Bulge
Image by Magnus Manske
Asymptomatic Disc Herniation
Image by User: Tonbi_ko
In one of the first studies of its kind, George Washington University Medical Center Orthopedist, Dr. S.W. Wiesel started the ball rolling with a study published in the September 1984 edition of the medical journal Spine (The Incidence of Positive CAT Scans in an Asymptomatic Group of Patients).  "In order to study the type and number of CAT scan abnormalities of the lumbar spine that occur in asymptomatic people, 52 studies from a control population with no history of back trouble were mixed randomly with six scans from patients with surgically proven spinal disease, and all were interpreted by three neuroradiologists in a blinded fashion. Irrespective of age, 35.4% were found to be abnormal.  In the over 40-year-old age group, there was an average of 50% abnormal findings.At least 35% abnormalities in asymptomatic individuals.

Six years later, in the March 1990 edition of the American Volume of The Journal of Bone and Joint Surgery, renowned orthopedic surgeon Scott Boden, also working at GWU Medical Center, followed up with a paper titled, "Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation".  In it he said that, "We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain or sciatica. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects.  About one-third of the subjects were found to have a substantial abnormality.  Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus.  In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects."   At least 35% abnormalities in asymptomatic individuals.

1994 saw yet another study published on this topic.  Dr. Maureen Jensen's "Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain" published in the July 14 issue of the New England Journal of Medicine.  In this study we learned that, "Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels.  52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk.  On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental. "   Over 50% of asymptomatic individuals had Disc Bulges.

In 1995, Volvo's 'Clinical Sciences Study of the Year' (The diagnostic accuracy of magnetic resonance imaging) was published in the December issue of SpineThe present study has presented evidence that.... asymptomatic patients show a high incidence rate of disc herniations (76%).  Individuals with minor disc herniations (i.e., protrusion, contained discs) are at a very high risk that their magnetic resonance images are not a causal explanation of pain because a high rate of asymptomatic subjects (63%) had comparable findings.     I must make note of the fact that this study also found that a whopping 85% of the asymptomatic subjects had class 3-5 DISC DEGENERATION on MRI as well.  At least 75% of asymptomatic individuals had Disc Herniations.

A few years later, a group of prominent Swiss researchers, led by Dr. Weishaupt of Zurich's Orthopedic University Clinic's Department of Diagnostic Radiology, got their hands on 60 hospital employees with no history of back pain.  The research team ran all of them through MRI's of the lumbar spine.  Even though the paper's conclusion infers that MRI is a wonderful tool for diagnosing back pain in the under-50 crowd, reading between the lines leads one to a different conclusion.  40% of the volunteers had "Disc Protrusions" even though they did not have back pain.  Even more amazing was that almost 1 in 5 of the test subjects had a "Disc Extrusion" (severe Disc Herniation). The results were published in the December 1998 issue of the journal RadiologyAlmost 20% of the asymptomatic individuals studied had 'severe' Disc Herniations.

*INCREDIBLE STUDY
*In Y-2K, Dr. Michael Raskin (M.D. / Attorney) got into the mix with a paper he published in Applied Radiology.  In the paper, whose topic pertained to the difficulty of accurately diagnosing personal injury clients, he exposed one of the dirty little secrets that hundreds of thousands of people on SSI Disability have known for years --- essentially that back injuries are easily faked.  "Asymptomatic individuals with "abnormal" MRI--Recent literature has shown that many anatomical abnormalities of the back, including disc bulges and disc herniations, are quite common in people without back pain.  Even prior to magnetic resonance imaging (MRI), the high incidence of disc abnormalities in the lumbar spine of asymptomatic individuals was quite well known. In 1956, a study using postmortem examinations of the entire spine showed a 39% prevalence of posterior disc protrusions.  In 1968, a study using myelography in 300 asymptomatic individuals demonstrated lumbar disc abnormalities in 24%.  Using computed tomography (CT), a 1984 study reported the prevalence of herniated discs in asymptomatic individuals to be 20% in those under the age of 40 years and 27% in those over the age of 40.  Since MRI became a clinically available diagnostic imaging tool in the mid 1980s, multiple studies have confirmed that more than half of adults without symptoms have significant disc bulges or disc herniations.  Furthermore, the prevalence of [asymptomatic] disc herniations increases with age. We have known that there is a huge prevalence of asymptomatic Herniated Discs since 1956.

A study published one year later in the journal Spine came to similar conclusions.  According to the University of Washington's Department of Radiology, "Back pain is the second most common symptom-related reason for clinician visits in the United States. Up to 84 percent of adults have low back pain at some time in their lives." But despite this, as well as the incredible numbers of MRI's being done here in the United States, the authors concluded that, "Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use.Read the previous two sentences.

And what if you are one of those people who has already had a back surgery?  The scientific literature speaks to you as well.  Just a little bit over a year ago, a group of six researchers working at Vanderbilt University Medical Center in Nashville, Tennessee, concluded their study on post-surgical asymptomatic Disc Herniations by saying that, "Nearly one-fourth of patients undergoing lumbar discectomy demonstrated radiographic evidence of recurrent disc herniation at the level of prior surgery, the majority of which were asymptomatic..... Clinically silent recurrent disc herniation is common after lumbar discectomy. "  Their findings were reported in the December 2011 issue of Spine.   This was not new information.

A 1995 offering, this time by Dr. RD Fraser and his team from South Australia's Department of Orthopedics and Trauma, Royal Adelaide Hospital, had this to say in that year's March edition of Spine.  "The findings of this study indicate that long-term improvement of a patient's symptoms after treatment of disc herniation may occur with or without resolution of the herniation. This and the similar findings in the different groups is consistent with the 10-year clinical results after the treatment of disc herniation reported by Weber."  This was the conclusion after looking at groups that were treated in various ways for herniated discs, and noticing that after a decade, 37% of the people in the study still showed herniated disc on MRI.  Interestingly enough, there was no rhyme or reason for who hurt and who did not simply by looking at their MRI.     Between 25% - 37% of post-surgical asymptomatic patients showed Herniated Discs after their surgeries.

YOUR CONVINCED.
BUT WHY DOES IT MATTER?

Great question.  Why does it matter?  Who really cares if you have Disc Herniations as long as they don't hurt?  Let me give you a couple of examples.  For one, research is now saying that if you have Asymptomatic Disc Bulges, they will likely not stay symptomatic forever.  This is good to know.  It may behoove you to check out the Top Ten Ways to Fix Your Own Back Problem on my THORACOLUMBAR FASCIA POST.  No, I am not suggesting for one second that you need to rush out and get an MRI.  I am saying that knowing this information could prove invaluable at some point in your life.  Let me give you another example --- one that I see several times a week in my clinic.

Let's say that you start having all the SIGNS OF A HERNIATED DISCAfter trying several things that did not help you, you had an MRI.  The MRI showed that you have DJD at three levels of the lumbar spine and two with DISC HERNIATIONS.   Your doctor wants you to do CORTICOSTEROID INJECTIONS, and when that doesn't work, he wants you to visit a Spinal Surgeon.   Even if you do not happen to be the sharpest knife in the cupboard, you know one thing ----- you know that people that have SPINAL SURGERIES don't usually do worth a flip.   All you have to do is ask them. 

BE WARNED:  If you do not realize what it really means that most Disc Herniations are asymptomatic, and that it is often quite difficult to correlate one's symptoms with what the MRI shows, you will be taken advantage of.  How do I know this?  For starters, look HERE.  Because there is big money in Spinal Surgery, it is not hard to grasp the fact that astounding numbers of people are having surgeries for problems that are not even the source of their pain!  This is one of the reasons that before I start Spinal Decompression on anyone who's Sciatica originates in the butt / hip instead of the low back, I make good and sure that they are not dealing with PIRIFORMIS SYNDROME first.

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_Mountain View, Missouri (West Plains / Willow Springs / Winona / Cabool / Summersville) ---- Spinal Decompression Doctor, Russell Schierling, presents another blog article on Spinal Decompression Therapy.

HERNIATED DISCS
A Picture (and several videos) Is Worth a Thousand Words
Herniated Disc
Image by user:debivort
_In the spine, there are 24 vertebrates.  In between these vertebrates are cushions called Intervertebral Discs.  If you'll notice the two pictures above, the picture of the one on the right is different from the one on the left.  On the right picture, the round aqua blue portion (the disc) is bulging back and pressing on the spinal nerve (blue).  This is a Herniated Disc.  But before we delve into the in's, out's, how's, and why's of Herniated Discs and what it takes to fix them, let's first touch on what a normal disc is, what it looks like, and how it behaves. 

Spinal Discs have several functions, but two stand out above the others.
  • They create space inside the Intervertebral Foramen:
  • They act as a "cushion" or "bushing" between the vertebrates:
The spinal bones (vertebrate) are held in place with ligaments, muscles, and tendons.  As you will see in the following diagrams, the Spinal Disc gives height to the Neural Foramen (often called the Intervertebral Foramen or IVF).  This is important to understand because the Spinal Nerves come off of the Spinal Cord, exit the spinal canal through the Neural Foramen (it's kind of like a "window" between any two adjacent vertebrate), and continue on to the various glands, muscles, organs, and tissues that they regulate and control.   As you will start to notice, the the Spinal Disc is made up of two distinct parts (look at the two different shades of aqua in the pictures above).  These are.......
  • The Outer Annulus:  The outer layer (or more appropriately, "layers") of the disc is called the Annulus Fibrosus and is made up of lots and lots of ligaments.  If you were to look at a Spinal Disc under a microscope, you would notice that the Annular Ligaments wrap around and around and around the center of the disc.  This is because The Annulus job is to hold The Nucleus (the jelly center) in place. How does it do this?  Think of a baseball here.  If you have ever cut open a baseball (or even an old golf ball), you will find lots and lots of rubber bands coiled around a center core.  Only instead of a core made of rubber or cork, the disc's core is made up of jelly.
  • The Inner Nucleus:  The Nucleus, technically called the Nucleus Pulposus, is the jelly-like center of the disc. Because it is a thick jelly-like fluid, it has the ability to push outwards in all directions. Bend to one side, and the disc tends to push toward the other. Bend forward, and the nuclear jelly pushes toward the back of the disc.
_Anything that encroaches on the Intervertebral Foramen (IVF) will compete with the nerve for space.  As you can imagine, it is not a good thing for the nerve to be pressed or encroached upon.  It's pretty easy to understand that the nerve needs a certain amount of room as it comes through the bony window we call the IVF.  When the nerve does not have the room it needs to stretch and move, it can become "pinched" or severely irritated.  As you can also imagine, this is not a good thing either.  How does this happen?  Follow along as I walk you through the process.

As the Spinal Discs bear loads, the pressure pushes the nucleus outward in all directions.   If there is a weak spot in the disc's outer Annulus, its most inner layers (near the Nucleus) begin to tear.  As they tear, the jelly center (The Nucleus) begins to push its way toward the outside.  Bear in mind that Disc Herniations rarely happen in the front part of the disc.  Because people tend to lean forward (not backward) and bend side to side, the pressure tends to push the nucleus toward the back of the disc.  This is where discs tend to rupture --- to the back and just lateral of the midline ---- where the spinal cord and spinal nerves are.


Full-blown Disc Herniations rarely happen all at once.  Much more common is a Progressive Disc Injury (diagram below).  As the disc is continually stressed, the annulus continues to tear just a little bit more; allowing the nucleus "slip" a little bit more ---- always creating a little bit bigger bulge and putting a just little bit more pressure on the nerve. But then it heals some, and might even feel better for awhile.  In other words, it's not an "all-or-none" proposition.  It is usually a process where a disc goes from normal to ruptured over time ---- even though the terrible pain might have come on all at once.  

And while you will hear terms bantered around such as "Slipped Disc," "Herniated Disc," Ruptured Disc," "Prolapsed Disc", etc, the question to ask is whether the disc is Contained or Non-Contained.  As long as the Nucleus is at least mostly contained within the Annulus, there is a strong possibility that conservative measures such as Spinal Decompression Therapy can help you avoid surgery.  But if the Nucleus slips completely outside of the Annulus ---- a "Non-Contained" lesion......   Unfortunately, you might have a surgical problem on your hands.   Unless your neurosurgeon says otherwise (AND MAYBE EVEN AGAINST THEIR WISHES), as long as you do not have severe leg weakness and / or loss of bladder or bowel function, you might want to consider Spinal Decompression Therapy!
Herniated Disc
user:debivort
_

CARDINAL SIGNS OF A HERNIATED DISC
Of course you can and probably should go for an MRI.  However, we know that 50% of the general population has disc herniations that show up on MRI's, but cause no pain or overt symptoms (HERE).  I am interested in physical findings that indicate a disc injury.  There are three Cardinal Signs that I look for in determining if someone might have at least some degree of Disc Herniation. They are.....
  • ANTALGIA:   An antalgic posture is leaning to one side or the other (or to the front).  If the Nucleus Pulposus "slips" or herniates to the right, most of the time people will lean to the left, and vise versa.  This is an automatic reaction of the body as it tries to pull you off of, or away from the bulging nucleus.  Often times you will notice that the belly button is pulled away from the body's center line.
  • POSITIVE VALSALVA or DeJARINE SIGN:  This is pain that occurs specifically when you cough, sneeze, or strain on the stool.  When you cough, sneeze, or strain, you develop a great deal of momentary internal pressure.  Because force always takes the path of least resistance, the pressure released by a cough or sneeze pushes on the injured (bulging) portion of the disc.  I frequently hear people tell me that if they know they are going to cough or sneeze, they hold themselves up on a counter or table so their legs do not collapse out from under them in sheer pain.  Speaking of legs......
  • SCIATICA:  The nerves from either side of your low back area grow together into one nerve ---- the Sciatic Nerve.  The Sciatic Nerve is not only the longest nerve in the body, it is the biggest as well (as big as your finger).  If you cause pressure on one of the nerves that makes up the Sciatic Nerve, you can end up in a world of hurt.  This can be in the form of pain.  But it can also be in the form of numbness, tingling, weakness, odd sensations (paresthesia), etc.  Sometimes the pain will do odd things like start at the knee and go down, or skip certain areas.  SCIATICA can manifest itself in an almost endless variety of ways.  It can mimic knee or hip problems as well.
            ANTALGIA    POSITIVE VALSALVA or DeJARINE SIGN   SCIATICA
      (leaning away from pain)     (severe pain when coughing or sneezing)        (leg symptoms)


_
_PIRIFORMIS SYNDROME:
One quick word about Piriformis Syndrome.  Piriformis Syndrome is literally a "pain in the butt" that can sometimes mimic a disc problem ---- even though it is caused by a problem with a muscle.  If you have little or no low back pain but lots and lots of buttock pain (or chronic Sacroilliac pain), this might very well be your problem ---- especially if you are female (notice the relationship of the Piriformis Muscle and the Sciatic Nerve in the picture below).  To understand the difference between a Herniated Disc and Piriformis Syndrome, please take three minutes and visit www.DestroyPiriformisSyndrome.com



MRI'S
OF
HERNIATED DISCS

This MRI is a lateral view of a person facing to your left.  The ling white line is the spinal cord.  The white areas on the left of the MRI are discs.  The fact that they are white indicates that they have water in them ---- a good thing.  Notice the circled area of one of the discs rupturing into the spinal cord.  The one below it is rupturing as well.  The disc is not white.  It is gray, fading to black.  This is indicative of a disc that is dehydrated.
Herniated Disc
Image by User:Tonbi_ko
Herniated Disc
Image by Edave


You can see the same thing in this MRI of the L4 Disc.  Notice how it is not only bulged, but is thinning as well.  This is called SPINAL DEGENERATION.  Note that the healthy discs are white on MRI, but the herniated discs are much darker, depending on their degree of degeneration.  This is a really good MRI to study.  It shows the progression of disc problems.  It starts with a normal disc at the L1-L2 disc, and ends with a Stage III Disc Herniation at L5-S1. 


DO NOT HAVE SURGERY WITHOUT TRYING CONSERVATIVE METHODS FIRST!

Have you been diagnosed with a Herniated Disc?  Maybe you have the Three Cardinal Signs of a Herniated Disc.  Whatever the case, DO NOT under any circumstances consent to spinal surgery without a second opinion.  Check out the internet message boards on the subject.  Visit the online support groups for people suffering from Failed Spinal Surgery Syndrome (FSSS).  Or better yet, talk to people you know who have had spinal surgery.  Ask them how they have done.  I promise you that over half of those you interview would not do it again ---- even if you paid them! 

Call Tracy today (417) 934-6337 to set up a free consultation with Dr. Schierling to see if Spinal Decompression Therapy MIGHT BE RIGHT FOR YOU  and your specific problem.