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Back Pain Guide 2

Ronald Grisanti D.C., D.A.B.C.O., D.A.C.B.N., M.S.
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Discogenic pain

Discogenic pain is a term Dr. Grisanti uses when referring to pain caused by a damaged intervertebral disc. A degenerating disc may cause pain of the mechanical type. As the disc begins to degenerate, there is some evidence that the disc itself becomes painful. Movements that place stress on the disc can result in back pain that appears to come from the disc. This is similar to any other body part that is injured, such as a broken bone, or even a cut in the skin. When these types of injuries are held still, there is no pain. However, if you move a broken bone, or the skin around a cut, it causes pain.

Discogenic pain usually causes pain felt in the lower back. It may also feel like the pain is coming from your buttock areas and even down into the upper thighs. The experience of feeling pain in an area away from the real spot causing the pain is common in many areas of the body, not just the spine.

Examples include: a person who has gallstones may feel the pain in their shoulder; or a person experiencing a heart attack may feel pain in the left arm. This is called radiation of the pain. It is very common for pain produced by spine problems, such as disc problems, to be felt in different areas of the body, including the back itself.

Bulging Disc

Bulging Disc are fairly common in both young adults and older people. They are not cause for panic. In fact, abnormalities that show up on MRIs, such as bulging or protruding discs, are seen at high rates in patients both with and without back pain. Most likely, some discs begin to bulge as a part of the aging process, and the degeneration process of the intervertebral disc. A bulging disc is not necessarily a sign that anything serious is happening to your spine.

A bulging disc becomes important when it bulges enough to cause narrowing of the spinal canal. If there are bone spurs present on the facet joints behind the bulging disc, the combination may cause narrowing of the spinal canal in that area. This is sometimes referred to as segmental spinal stenosis.

Herniated Disc

A Herniated Disc occurs when the intervertebral disc's outer fibers (the annulus) are damaged and the soft inner material of the nucleus pulposus ruptures out of its normal space. If the annulus tears near the spinal canal, the nucleus pulposus material can push into the spinal canal. This can cause too much pressure on the spinal cord and nerve roots.

There is also some evidence that the nucleus pulposus material causes a chemical irritation of the nerve roots. Both the pressure on the nerve root and the chemical irritation can lead to problems with how the nerve root works. The combination of the two can cause pain, weakness, and/or numbness in the area of the body to which the nerve travels. For this reason, a herniated disc usually causes pain of the compressive type. Sometimes a herniated disc is referred to as "slipped disc", though the disc does not actually slip.

Herniated discs are common in the lumbar spine because of all the pressure it supports. A herniated lumbar disc often produces sciatica. This is a condition where the lower back pain and numbness radiates down the back of the leg, side of the calf, and possibly into the side of the foot. You may not necessarily have much back pain.

The exact area where you will feel numbness depends on the nerve root that is affected; the numbness could be in the inner ankle, big toe, heel, outer ankle, outer leg, or a combination of them. Your doctor can use this information to get an idea which nerve is affected.

Pressure on the nerve root can cause the parts of the nerve that control the muscles not to work properly. This can result in weakness of some muscles and may change the reflexes in certain areas. Again, your doctor can use this information to try to determine which nerve is involved.

The same is true for the neck. A problem stemming from the neck may result in pain that is perceived in the arm or hand. However, a herniated disc is much less common in the thoracic spine. This is likely because the discs are much thinner and there is less material in the nucleus pulposus to rupture into the spinal canal. HOWEVER, if a herniated disc does occur in the thoracic spine, it can be much more serious than in the lumbar spine. The thoracic spine has very little extra room in the spinal canal.

In addition, a herniated disc in the thoracic spine puts pressure on the spinal cord - not just a few nerve roots. Too much pressure on the spinal cord from a herniated thoracic disc can lead to total paralysis from the waist down.

Just because a disc has herniated does not necessarily mean that you will need to undergo surgery. In most cases, a herniated disc can be treated without surgery. The treatment of a herniated disc depends on the symptoms. It also depends on whether the symptoms are getting steadily worse -- or whether they are getting better.

If the symptoms are getting steadily worse, your doctor may be more likely to suggest surgery. If the symptoms are getting better, your doctor may suggest watching and waiting to see if the symptoms go away. In many cases, the initial problems due to a herniated disc completely resolve over several weeks to months.

In rare cases, a herniated disc in the lumbar spine area can be so large that it fills the entire spinal canal in the area where it ruptures. When the spinal canal fills with disc material, it may place a great amount of pressure on the nerves. If this occurs in the lower spine, it can lead to a condition called "cauda equina syndrome".

This problem can lead to permanent paralysis of the muscles that control your bowels and bladder. If you lose control over your bladder or bowels, you should contact your health care provider immediately. This is an emergency!

Degeneration of the Intervertebral Disc

The process of degeneration of the intervertebral disc causes many problems in the spine. Everything you do during the day - once you stand upright - begins to test the spine's ability to support your body weight. Over time, these repeated daily stresses and minor injuries can add up and begin to affect the discs in your spine.

Minor injuries to a disc may occur and not cause pain at the time. However, as they add up, the disc eventually begins to suffer from the wear and tear - it begins to degenerate.

There is an intervertebral disc between each of your vertebra. The intervertebral discs are designed to absorb pressure and keep the spine flexible by acting as cushions during body movement. The discs work similarly to shock absorbers. They are like cushions in running shoes; without them, a jogger would feel every pound on the pavement, and the feet would soon tire out. Without the cushion effect of the discs, the vertebrae in your spine would probably fracture or break. Bones cannot sustain high stress repeatedly without being cushioned.

A healthy intervertebral disc has a great deal of water in the nucleus pulposus - the center portion of the disc. The water content gives the nucleus a spongy quality and allows it to absorb spinal stress. Excessive pressure or injuries to the disc can cause the injury to the annulus - the outer ring of tough ligament material that holds the vertebrae together.

Generally, the annulus is the first portion of the disc that seems to be injured. Small tears show up as in the ligament material of the annulus. These tears heal by scar tissue. The scar tissue is not as strong as normal ligament tissue. Over time as more scar tissue forms, the annulus becomes weaker. Eventually this can lead to damage of the nucleus pulposus. The nucleus begins to lose its water content due to the damage - it begins to dry up.

Because of water loss, the discs lose some of their ability to act as a cushion. This can lead to even more stress on the annulus and still more tears as the cycle repeats itself. As the nucleus loses its water content it collapses, allowing the two vertebrae above and below to move closer to one another. This results in a narrowing of the disc space between the two vertebrae.

As this shift occurs, the facet joints located at the back of the spine have to shift. This shift changes the way the facet joints work together and can cause problems in the facet joints as well.

Bone spurs, sometimes called osteophytes, may also form around the disc space. These bones spurs can also form around the facet joints. This is thought to be due to the body's response to try to stop the excess motion at the spinal segment. The bone spurs can become a problem if they begin to grow into the spinal canal and press into your spinal cord and nerves. This condition is called spinal stenosis.

Segmental Instability of the Spine

Each spinal segment is like a well-tuned part of a machine. All of the parts should work together to allow weight bearing, movement, and support. A spinal segment is composed of two vertebrae attached together by ligaments, with a soft disc separating them. The facet joints fit between the two vertebrae, allowing for movement, and the foramen between the vertebrae allows space for the nerve roots to travel freely from the spinal cord to the body.

When all the parts are functioning properly, the spinal segments join to make up a remarkably strong structure called the spine. When one segment deteriorates to the point of instability, it can lead to localized pain and difficulties.

Segmental Instability occurs when there is too much movement between two vertebrae. The excess movement of the vertebrae can cause pinching or irritation of nerve roots. It can also cause too much pressure on the facet joints, leading to inflammation of facet joints. It also may cause muscle spasms as the paraspinal muscles try to stop the spinal segment from moving too much. The instability eventually results in faster degeneration of the spine in this area.

It is hard to determine which problem comes first in segmental instability. In some cases, degeneration of the disc begins the process. Once the disc is no longer able to function normally, the degeneration process of ALL parts of the spinal segment begins. As the disc continues to degenerate, the facet joints become arthritic, bone spurs form around the joints, and the segmental instability gets worse.

Diagnosis

Before Dr. Grisanti can diagnose your condition and design a treatment plan, a complete history and physical examination are necessary. There are so many possible internal causes of pain; it is important to determine what is and is not causing the problem. After Dr. Grisanti has a better idea of what is attributing to your discomfort, diagnostic tests of some sort may be recommended.

History

First, you will be asked for a complete physical history of your condition. This may begin by filling out a written form that asks you a number of questions relating to your pain. The more information you share with Dr. Grisanti, the easier your problem will be to diagnose.

Your physical history is important because it helps Dr. Grisanti understand: when the pain began, anything that could have caused an injury, your lifestyle, physical factors that might be causing the pain, and your family history of similar problems. After reading through your written history, Dr. Grisanti will ask more questions that relate to the information you have given.

Some typical questions include:

  • When did the pain begin?
  • Was there an injury that could be related to the pain?
  • Where do you feel the pain? What is the intensity?
  • Does the pain radiate to other parts of the body?
  • What factors make the pain feel better or worse?
  • Have you had problems with your bladder or bowels?
  • Is there a history of osteoporosis in your family?

    Physical Examination

    After taking your history, Dr. Grisanti will give you a physical examination. This allows him to rule out possible causes of pain and try to determine the source of your problem. The areas of your body that will be examined depend upon where you are experiencing pain - neck, lower back, arms, legs, etc.

    The following are some of the things that are checked in a typical exam:

  • Motion of Spine and Neck - Is there pain when you twist, bend, or move? If so, where? Have you lost some flexibility?

  • Weakness - Your muscles will be tested for strength. You might be asked to try to push or lift your arm, hand, or leg when light resistance is put against them.

  • Pain - Dr. Grisanti may try to determine if you have tenderness of certain areas.

  • Sensory Changes - Can you feel certain sensations in specific areas of the feet or hands?

  • Reflex Changes - Your tendon reflexes might be tested, such as under the kneecap and under the Achilles tendon on your ankle.

  • Motor Skills - You might be asked to do a toe or heel walk.

  • Special Signs - Dr. Grisanti will also check for any "red flags" that could indicate something other than spinal/vertebrae problems. Some signs of other problems include tenderness in certain areas, a fever, an abnormal pulse, chronic steroid use (leads to loss of bone mass), or rapid weight loss.

    Back Pain Guide Part 3 Continued




    Before starting any self treatment Dr. Grisanti recommends that you consider consulting with a doctor trained in functional medicine. Visit www.FunctionalMedicineUniversity.com to find doctors thoroughly trained in functional medicine

    Functional medicine embraces the totality of the regulatory functions of the body. It encompasses all of the biophysical, biochemical, enzymatic, endocrine, immunological, and bioenergetic regulatory capacities.

    Ronald Grisanti D.C., D.A.B.C.O., D.A.C.B.N., M.S.