pathology: disc hernia (intervertebral disc disease)

yogabook / pathologie / disc hernia (intervertebral disc disease)

disc hernia (intervertebral disc disease, diskosis, chondrosis intervertebralis, disk degeneration)

Definition of

There is one intervertebral disc between every two adjacent vertebrae except between the atlas and axis, 23 in total. The intervertebral discs are bradytrophic and are only supplied by diffusion. Their task is to distribute pressure and buffer between the vertebral bodies, which they fulfill very well due to their high water content in a healthy state according to Pascal’s principle. Physiologically, they age in two ways: the water-binding macromolecules of the nucleus pulposus become fewer and also change qualitatively, which leads to less water storage and reduced pressure absorption and a change in the environment in the direction of acidity in the intervertebral disc. In addition, the annulus fibrosus has a low regenerative capacity. Physiological ageing leads to reduced height of the intervertebral discs and a tendency towards osteoarthritisof the facet joints with the development of facet syndrome. When a herniated disc occurs, the respective nucleus pulposus is hardly present. The average age of onset is 40 years, although incidents have also been observed in children. In older, asymptomatic patients, herniated discs are found as an incidental finding in 60% of examinations. The ratio of herniated lumbar spine to cervical spine is approx. 100-10-1, with the lumbar spine usually affected at L4/L5 or L5/S1, followed by the cervical spine at C5/C6 and C6/C7. The severe pain is possibly not/not solely caused by nerve root compression, but (also) by inflammation and immune reactions with which the body reacts to the over-acidified leaking mass. Surgical treatment is usually not the method of choice; it is often only apparently superior in the first 24 months afterwards, after which the success of conservative therapy, which relies more on proactive action and stress avoidance by the patient, pays off for the most part. Displacement of disc tissue in 3 possible directions:

  1. ventral: without clinical symptoms
  2. dorsal: emergency: paraplegic symptoms ( cauda equina syndrome in the lumbar spine)
  3. medio-lateral or dorso-lateral: unilateral neurological compression symptoms, symptoms of lumbalgia or sciatica

By severity:

  1. Low: Protrusion (protrusion) with preserved annulus fibrosus, there is mainly an intradiscal mass displacement
  2. Medium: Prolapse, partial exit of the nucleus pulposus due to tearing of the annulus fibrosus, usually with additional perforation of the ligamentous apparatus of the spine
  3. maximum: sequestrum formation: after injury to the posterior longitudinal ligament, intervertebral disc tissue is squeezed out

The extent of the symptoms does not allow any statement to be made about the type of disorder. The disc hernia must not be confused with the comparatively harmless lumbago. Peak around the age of 40. Mainly lumbar spine, also cervical spine, very rarely thoracic spine. In 90% of cases, the lumbar spine is affected at L4L5 or L5S1 and otherwise other parts of the spine, especially the cervical spine.

ICD M51

Cause

  1. Age-related degeneration
  2. Chronic overload
  3. Capsuloligamentous injuries
  4. Vertebral body fractures
  5. Structural disorders of individual movement segments such as spondylolisthesis, scoliosis

Predisposing

– Musculoskeletal system

  1. Pre-damage to the intervertebral discs
  2. Unphysiological posture and strain, in particular prolonged activities with the trunk bent forward, weight training with unrecognized malpositions/postures; often prolonged static positions
  3. Weakness of the paravertebral muscles in particular
  4. Genetic connective tissue weakness

– Other health factors

  1. Age
  2. Pregnancy
  3. Overweight

– Behavior

  1. Lack of exercise, office work
  2. Certain professions such as nursing care for the elderly/nurses
  3. Standing with a hollow back
  4. Technical deficiencies in lifting and other hip-flexing activities

Diagnosis

  1. Contrast X-ray, discography (contrast medium is injected into the intervertebral discs under X-ray control)
  2. MRI
  3. Tests and signs: Lasegue sign, Kernig sign

Symptoms

  1. Severe, sometimes shooting pain, often radiating to the extremities (depending on the area supplied by the affected nerve)
  2. In the case of protrusion, usually only local pain caused by irritation of the posterior longitudinal ligament
  3. Stepped bed position or other supine position with flexion in hips and knees improves
  4. Sneezing, pressing, coughing worsens
  5. in more severe cases, possibly paralysis. A distinction is then made between degrees of strength: reflex failures, sensitivity disorders, etc. are also possible. For the most affected segments/nerves these are:

Complications

  1. Recurrence
  2. Recurrence in neighboring segment after surgery

Therapy

  1. conservative if possible
  2. Analgesics if necessary
  3. In the case of persistent or increasing sciatica or brachialgia, surgery if necessary
  4. NO bed rest if flexibility is maintained! If flexibility is impaired Anangetics/NSARs
  5. Manual medicine such as chiropractic only for non-radiating pain
  6. KG for chronic and subacute pain; there is no proof of efficacy for acute pain
  7. Alternative forms of therapy such as Feldenkrais, Alexander Technique, Hatha Yoga, McKenzie Concept, Spiral Dynamics, acupuncture
  8. Behavioral therapy for pain management
  9. For pain radiation: back training
  10. Periradicular therapy (PRT): at least two cortisone injections under X-ray/CT control; relieves pain in 67% of cases
  11. Surgery only if strictly indicated due to risks of adverse effects:
    1, cauda equina syndrome with acute paraparesis in the case of extensive disc herniation or in the case of a vertebral body
    2. bladder and rectal paralysis
    3. increasing or acute severe muscle deficits
    or as a last attempt in the case of pain that cannot be tolerated after all available treatment methods have been used. Complications of the operation are
    1. frequent postoperative scarring, which can, for example, pinch the nerve root or the dural sac
    2. frequent relapse/recurrence due to unresolved structural weakness of the back and further muscular destabilization as a result of the operation
    3. sometimes severe infection, possibly with abscessing
    4. cerebrospinal fluid leakage (cerebrospinal fluid) in the event of injury to the dura, e.g. with severe headaches
    5. the recurrence rate for microsurgery is > 10 %
    The most common surgical methods:
    1. microdiscectomy through 3-5 cm incision
    2. minimally invasive surgery and microsurgical procedures
    3. on the rise: endoscopic transforaminal disc surgery
  12. such as percutaneous laser disk decompression (PLDD), show a positive effect despite
  13. smaller scar, however, no better results
  14. Hospitalization only in the case of pain that cannot be controlled on an outpatient basis and increasing neurological deficits as well as the following „red flags“:
    1. accident
    2. trauma or minor trauma with osteoporosis
    3. tumor history
    4. infection
    5. weight loss
    6. fever
    7. increased pain at night
    8. progressive nerve loss
    9. decreasing pain and paresis
    10. cauda equina syndrome
    11. micturition disorder (typically urinary retention, overflow bladder, possibly incontinence)
  15. There are several newer therapeutic approaches for intervertebral disc degeneration:
    1. stabilization of perforated disc shells with annulus prostheses such as Barricaid
    2. injection of water-binding polymers to increase the water content of the intervertebral discs
    3. implantation of in vitro cultured vital chondrocytes, i.e. the body’s own intervertebral disc cells (ADCT)

DD

  1. Cauda equina
  2. Nerve root compression syndromes of various origins
  3. Facet syndrome
  4. Spinal canal stenosis (typically increasing discomfort when walking and bending backwards)
  5. Cox arthrosis (typically increased pain with rotation in the hip)
  6. Sacroiliac joint arthrosis (typically pressure-sensitive)
  7. Facet joint arthrosis (typically only localized back pain without radiating to the arms or legs)
  8. neuroforaminal stenosis (e.g. in facet jointarthrosis)
  9. postoperative scar tissue
  10. Bannwarth syndrome (Lyme disease stage II)

Asana practice and movement therapy

In the case of disc herniations in the lumbar spine, which are by far the most common, even a slight convex curvature of the lumbar spine, i.e. kyphosis, should be strictly avoided as far as possible. This also applies beyond a longer period of time after which the classic symptoms, i.e. pain radiating beyond the buttocks into the leg, possibly with numbness, tingling, burning or muscular deficits, last occurred. A kyphotic, passive posture during sedentary work during the day, possibly in combination with an equally kyphotic sitting posture at home in the evening, is often the cause of the development of the disc disease. If there is also insufficient sleep at night or an unfavorable, curved position of the spine during sleep, the ability of the intervertebral discs to regenerate at night and reabsorb fluid that has been pressed out during the day is also restricted.

The requirement not to bend the lumbar spine means that all activities in which the hands are held lower than they are in anatomically zero by flexion in the hip joints with a straight back or bending the knee joint with flexion in the hip joints must be undertaken. This is the only way to lift objects from the floor or deep shelves. However, this has physiological movement prerequisites. The deeper knee bend requires some strength, especially in the quadriceps and gluteus maximus, but also in the hamstrings. A further prerequisite is sufficient flexibility of the soleus, as this can limit the dorsiflexion of the ankle joint (OSG) to such an extent that further flexion of the knee joint would lead to falling backwards. The other strategy of flexing the hip joints requires even greater muscular competence than the first. Although the quadriceps are required much less depending on how the knee joint is bent, the hip extensors, especially the hamstrings, must be sufficiently strong. Only trained individuals should be able to lift the weight of a crate of lemonade or beer from the floor using the strength of the hamstrings with a straight back without bending the latter to relieve the hamstrings by shortening the effective lever arm. In the second case in particular, the autochthonous back muscles must also be sufficiently strong and the proprioception to keep the back straight must be sufficiently pronounced. Flexibility of the soleus is hardly required here, but strength of the entire triceps surae, which must support the load lever of the upper body with the short power lever of the foot.

In contrast to flexion of the lumbar spine, extension can generally be performed and practiced without hesitation, unless other entities would contraindicate this. Sometimes this movement is also sought involuntarily by those affected. In practice, there are many cases in which shortening of the hip flexors is associated with intervertebral disc disease. There is no direct causal link, but both conditions can be caused by a sedentary lifestyle with a lack of proactive physical activity. It must be assumed that a shortening of the hip flexors during frequent phases of standing or continuous standing activity leads to an increased load on the intervertebral discs in passive sitting postures with kyphosis of the lumbar spine via the hypertonus of the autochthonous muscles in the area of the lumbar spine resulting from the hollow back and thus increases the tendency to intervertebral disc disorders. After flexion of the lumbar spine as the most important trigger of disc complaints, lateral trunk flexion and, to a much lesser extent, rotation of the lumbar spine are also possible pain triggers. This is due to the fact that symptomatic disc disorders are caused by pressure on the spinal nerves emerging dorsolaterally from the spinal canal. Lateral compression of the intervertebral discs by lateral flexion of the spinal column can therefore also increase the pressure on the nerves, so that these movements and postures must also be avoided. The rotations of the spinal column are generally much less critical and only rarely lead to an increase, triggering or recurrence of symptoms, which is due to the fact that they hardly cause any additional pressure on the intervertebral discs, apart from, for example, increased tension in the rotationally active oblique abdominal muscles.

For asana practice, this means that forward bends such as uttanasana and other standing forward bends should be performed with the back straight. This can be done, for example, in the sense of the table variation or the right-angled uttanasana. Seated forward bends are contraindicated, especially for less flexible people, as they involve far more risk than benefit. Side trunk bends such as seated side trunk bend or parighasana should also be avoided. If there is tension or a subjectively uncomfortable tone in the lateral flexor muscles, such as the oblique abdominal muscles, this should be countered with postures in which these muscles are worked without lateral flexionand with a medium sarcomere length, as is the case in trikonasana, vasisthasaha or ardha vasisthasana and ardha chandrasana. This can often already lead to a reduction in excessive tone or tension without creating a real stretch through lateral flexion, which is associated with a clear likelihood of the symptoms flaring up again.

In the case of intervertebral disc disorders, the physical constitution and the exercise and posture habits must be evaluated in order to pursue a multifactorial approach, as is often advised in chronic cases. In addition to a lack of exercise and unhealthy, prolonged sitting postures, either unphysiological physical strain, such as in geriatric care, or a less muscularly competent body are often partly responsible for the development of disc disease. Previous diseases of the musculoskeletal system, including those that burn themselves out, such as Scheuermann’s disease, can also be responsible. Strengthening of the back muscles, stretching of the hip flexors if they are not flexible enough and competence of the hip extensors, which maintain the extension of the back when bending forward with a straight back, should be acquired and trained. Training of the abdominal muscles, especially the rectus abdominis, is often prescribed for back problems. Although a stable „core“ is certainly always helpful, the function of the rectus abdominis, which moves the sternum caudally and thus curves the area of the lower thoracic and lumbar spine, must be taken into account. Its tone also makes inhalation more difficult. The rectus abdominis will also never be able to compensate for the effect of shortened hip flexors, and certainly not without making inhalation dramatically more difficult. Strengthening the hip extensors as antagonists of the shortened hip flexors, which have a direct and also incomparably more competent effect, is the starting point of choice here.

Herniated discs in the cervical spine follow those in the lumbar spine at a considerable distance. The situation here is comparable. Again, flexing postures and movements of the spine must be avoided. In some cases, even a few degrees of flexion can trigger the neuroradicular pain again, which usually radiates into the arm and can lead to afferent numbness and efferent motor deficits. As in the case of the lumbar spine, stretching with flexion is therefore not permitted if the muscles feel tense, but only movements of short to medium sarcomere length may be performed to loosen the muscles, with those of medium sarcomere length in particular providing relief from tension.

In the asanas, not only the posture itself should be considered, but also how it is assumed. In principle, for example, a 3rd warrior pose backwards against the wall would be a very suitable pose to strengthen the back, but the typical way of assuming the postures from a position supported by the fingers on the floor is contraindicated in the case of disc problems in the lumbar spine. The 3rd warrior pose itself, on the other hand, is an excellent pose when held from urdhva hastasana. It is important to ensure that the upper body is not lowered faster than the pelvis is tilted.