Disc herniation or herniated disc affects a high percentage of people but fortunately only a small portion of them develop symptoms. In fact, the pain and the symptoms of the herniated disc are due to the escape of the nucleus pulposus (but also to a deformation of the disc as a whole). Then, the contents of the nucleus come into contact with the spinal cord and the origins of the nerves, compressing them.
But, the type of intervention is variable even if it tends to be conservative and is closely related to the symptomatology, pain and quality of life of the patient. Conservative therapy is characterized by the administration of drugs, a recovery of motor function and a muscle strengthening activity aimed at prevention.
However, in the most serious cases or in the presence of comorbidities (other pathologies that worsen the state of health and the symptoms of the hernia), the doctor may consider surgery.
Herniated disc: what it is
Disc herniation is one of the pathologies that can affect the intervertebral disc. It is the fibrous ring that contains the nucleus, a degeneration of this structure would therefore allow the pulpy nucleus to penetrate between the broken fibers. Once the nucleus is able to penetrate between the fibers of the fibrous ring, two main scenarios initially open.
In fact, not all fibers are broken and therefore the core is still contained within the disc . But with its outward pressure, it causes the entire disc to protrude outside the physiological margins. So, we are facing a disc protusion . The disc is damaged, losing its alignment with the vertebral bodies but keeps the nucleus inside.
Furthermore, when all the fibers of the fibrous ring break and the nucleus pulposus comes out of the intervertebral disc , in this case we can speak of a herniated disc.
However, this condition has different nomenclatures, definitions and characteristics based on the type of spill and the migration zone of the pulpy nucleus.
The lumbar area is the most affected by this type of hernia, followed by the cervical area.
Herniated Disc : epidemiology
The real epidemiology of disc herniation is unknown. First of all because currently there is no shared classification from the pathological point of view and instrumental diagnosis. Hence, even literature does not help on the common definition of symptoms.
The hernia can be asymptomatic, with an incidence of between 20% and 40% for contained hernias and from 1% to 8% for expelled hernias. In this case, the available literature agrees on the definitions of disc diseases, however the difference in data between studies remains high. Hence, estimates report between 5% and 10% of patients with low back pain associated with radiculopathy (when the hernia comes into contact with one or more nerve roots).
While between 1% and 3% of the population complains that they have had at least one episode of radiculopathy during their lifetime.
In addition, people between 30 and 50 are the most affected , with a peak around 40 and over 90% of cases locate the hernia at levels L4-L5 and L5-S1. Finally, in lower percentages it is possible that the hernia also occurs in young and elderly subjects.
The vertebral column is made up of 33 vertebrae placed one after the other. Each vertebra is connected to the other two adjacent by means of the articular facets , which are joints positioned in the posterior part of the vertebra which allow movements on all planes.
Between one vertebra and the other, there is the intervertebral disc, positioned in the front of the vertebra, resting on the vertebral body. The disc has two main functions : absorbing and dissipating forces and giving stability to the vertebrae.
The function of the spinal column is therefore of protection, support and mobility.
Divided into the cervical, dorsal, lumbar, sacral and coccygeal tracts, it plays vital roles , including that of protecting the intrathoracic organs by forming, together with the ribs, the posterior wall of the rib cage.
Instead, the sacral tract delimits the posterior wall of the pelvis and protects its contents. But, another vital function of the vertebral column is that of the protection of the spinal cord that runs inside it, in the vertebral canal. The spinal cord originates from the brain and extends to the first vertebrae of the lumbar tract, from there a series of nerve bundles reach the last coccygeal vertebrae.
Spinal nerves and other nerve structures originate from the spinal cord . The spinal nerves come out of the intervertebral hole, a space between two vertebrae, and then branch off inside the body and reach the areas to be innervated.
The spine has four curves in adults that allow it to support the entire weight of the body :
cervical and lumbar region have a lordotic curve (lordosis)
dorsal and sacral regions a kyphotic curve (kyphosis).
Furthermore, it is interesting to note that kyphosis is present in the most “protected” areas of the body , where the most delicate and vital organs are found. Therefore, they are basically less mobile areas . While lordoses have greater freedom of movement and can adapt much better to postural, structural and visceral variations of the body.
The intervertebral disc is a ring-shaped fibro-cartilaginous structure, positioned between the vertebral bodies of two adjacent vertebrae. Inside it has a pulpy core delimited by layers of collagen fibers (fibrous ring).
It is mainly composed of water which makes it minimally compressible. So, in this way, it can perform its function of dissipating forces and at the same time stabilize the spinal column, allowing it to move.
The movements of the column are given by the sum of the degrees of movement of the individual vertebrae. In fact, each vertebra has limited degrees of movement but which on the whole allow the vertebral column to perform excursions on the various planes.
Herniated disc: because the disc nucleus comes out
The function of the fibrous ring is to protect the nucleus. In fact, it is a structure capable of deforming to adapt to stresses and dissipate forces. However, a laceration of the fibrous ring , made up of lamellae, leads the nucleus to migrate towards the outside of the disc giving rise to various pathologies of the disc, among which the herniated disc .
But, the interverbral discs don’t have equal dimensions on the whole column . For example, in the lumbar tract they are more massive precisely because they have to bear greater stresses . Hence, it is precisely the lumbar tract that is the most stressed of the whole spine. In this area, from the biomechanical point of view, a confluence of forces arriving from the upper and lower part of the body can be observed.
It is no coincidence that over 90% of herniated discs occur in the lumbar region.
Types of hernia
Usually, when we talk about a hernia, we often mistakenly imply a type of herniated disc. But in reality, there are several structures and regions in the body that can present hernias.
In fact, a hernia defines any type of spillage of a bowel from its own cavity which physiologically contains it.
So, hernias can be diaphragmatic, abdominal and cerebellar, as well as the disc.
The inguinal hernia is among the most common hernias ever. It is caused by a weakness, usually congenital, of the area of the inguinal canal. Thus, the consequence of a weak containment “wall” is the leakage of the abdominal viscera that creep into the groin area.
Instead, the known hiatal hernia is included among the diaphragmatic hernias . This is a particular condition because due to a defect in the esophageal hiatus , a narrowing managed by the fibers of the diaphragm, the initial part of the stomach tends to herniate.
In this way, the stomach portion moves into the supra-diaphragmatic space usually occupied by the esophagus. Thus, the esophageal hiatus, by losing its containment function in the stomach, in addition to making it rise, gives the possibility of the stomach contents and gastric juices to rise up into the esophagus.
Discover our insight on hiatal hernia .
Instead, the abdominal hernia is a leaking of the viscera in a zone of weakness of the abdominal wall. This weakness can be congenital or secondary to pregnancy, obesity and trauma. But, it is possible that the hernia is asymptomatic or that the patient reports gastrointestinal symptoms .
Finally, there are cerebellar hernias : they are life-threatening hernias and almost always secondary to a pathology, for example a tumor. The skull, being made up of rigid joints, does not have the possibility to adapt to the presence of a new formation.
Therefore, consequently, the content will try to move, driven by the increase in pressure, towards the spaces available to be occupied.
Herniated Disc : symptoms
Herniation and disc protusion often have a common symptomatology, for this reason the best method of investigation remains the instrumental examination. However, the clinical examination is not enough to lead to a diagnosis .
Furthermore, the herniated disc can present itself without symptoms when it does not come to compress any nerve roots or generate excessive tension on the posterior longitudinal ligament.
A disc protusion or a hernia can be asymptomatic in most subjects, other times it can lead to the classic neurological symptoms.
But, when the hernia comes into contact with one or more nerve roots , compressing them, it triggers more or less severe pain depending on the degree of compression and the affected root (radiculopathy).
Hence, the neuropathic pain of the hernia is the classic shock that originates near the spine and radiates following a precise path, the path of the compromised nerve. For example, in cervical hernia, pain can originate from the neck and will radiate into the area of the trapezius, shoulder and up to the hand.
Instead, in a lumbar hernia , from the spine it runs down the thigh and leg to the toes.
Furthermore, a lack of sensitivity and an inability to contract the muscles innervated by the compromised nerve may be associated with nerve-type pain.
Hence, the origin of radiculopathy is complex and can be considered as a set of mechanical and inflammatory factors. They are mechanical because there is actually a mechanical compression of a nerve root causing a deformation of the nerve fibers and a series of indirect effects on microcirculation.
Furthermore, the pain of a hernia can also be triggered by the excessive tension of the posterior longitudinal ligament , which adheres to the intervertebral disc.
All the problems of the organs innervated by the roots in compression due to the hernia must be added to the symptoms of the herniated disc. For example, problems with the urogenital, intestinal and sexual spheres are just some of the possible problems related to a herniated cervical or lumbar disc.
Herniated Disc : diagnosis
The first step in diagnosing a herniated disc is based on a careful medical history and subsequent clinical examination. The goal of the first approach is to make a differential diagnosis, that is to exclude other possible causes and pathologies with symptoms similar to disc herniation.
However, the differential diagnosis in cases of low back pain with radiculopathy is very complex. In fact, the causes of these symptoms are numerous and often difficult to exclude . But, of fundamental importance, as in any anamnesis, are the so-called “red flags”. By “red flags” we mean all those signs and symptoms that can indicate a medical emergency . In this case it will be necessary to intervene immediately with in-depth diagnostic and medical therapies.
From the results of the clinical examination it will be the discretion of the doctor to decide to investigate further with instrumental tests such as magnetic resonance imaging and computed tomography (old CT scan).
Magnetic resonance imaging (MRI) is recommended as the main diagnostic test , as it allows you to examine all the structures of the spine and is a non-invasive examination.
Instead, CT is an instrumental investigation method indicated in patients who cannot undergo magnetic resonance imaging or if the results of MRI have not been satisfactory.
Herniated Disc : treatments
But, before delving into the possible treatments for disc herniation, it is appropriate to open a parenthesis on the possible evolution of the pathology.
Although the natural history of the herniated disc is not fully known, the hypothesis of spontaneous hernia regression is supported by literature .
In fact, studies report that most herniated discs will shrink over time and most patients will improve regardless of the type of treatment.
In fact, in these cases, the symptoms seem to be related to the volume of the hernia , therefore, consequently a reduction in volume will lead to a decrease in symptoms.
Famacological treatment is generally the first approach in case of symptoms caused by herniated disc. But, the doctor will evaluate the types and dosages of drugs to be administered to the patient.
Usually, in cases of mild or moderate symptoms, we proceed with the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) to act on the inflammatory state and reduce the symptoms.
Pain relievers can be prescribed to relieve pain and improve disease management.
In the event that these drugs are not effective, the doctor may indicate the use of corticosteroids. In fact, compared to NSAIDs they have a more aggressive action on inflammation and pain . Cortisone injections are the most common in cases of lumbar and / or cervical disc herniation.
But, muscle relaxants may also be associated with NSAIDs or corticosteroids . The goal is to relax the muscles and consequently improve the pain situation. In fact, the injection of muscle relaxant associated with corticosteroids is a common treatment in the pharmacological management of the herniated disc with important symptoms.
The physiotherapist can work on the symptomatology with instrumental therapies, such as Tecar and active and passive mobilizations of the affected areas. In addition, it can be useful in the early stages of symptoms to limit further deterioration and rehabilitate the joints and muscles innervated by compromised nerves.
The osteopath can work on the functional recovery in a non-acute phase of the herniated disc . With manipulation techniques it can promote recovery and restore posture using delicate but effective treatments to which exercises will be associated.
Surgical treatment of lumbar or cervical disc herniation is limited to approximately 10% of all patients with this pathology. Hence, it is clear that conservative treatment is the most suitable one in most cases.
The surgery has the objective of removing the herniated part and decreasing the volume of the nucleus which goes to compress the nerve root and the posterior longitudinal ligament. But, the operation is indicated in the event that the symptoms are severe and disabling or if the patient does not respond to conservative therapy.
Herniated Disc and gym
Muscles to be toned
For a variety of biomechanical factors, practically all the muscles in the body can affect the functioning of the spine.
First of all there is the gluteus , a very strong muscle that originates in the posterior area of the pelvis (Ileus) and is inserted on the femur. The buttock is among the main responsible for the stability of the pelvis and lumbar spine because it exerts an important lever on the hip and pelvis area. He intervenes in numerous movements of daily activities such as climbing stairs or standing up from a squatting position.
The iliopsoas muscle with its origin precisely on the lumbar intervertebral discs, together with the posterior muscles of the thigh, the square of the loins and the abdominal rectum contributes directly to the management of the lumbar tract. But, as mentioned above, the lumbar and cervical tracts have a lordotic curve (lordosis). Hence, the maintenance of lordosis, as well as other curves, is fundamental for the prevention of lumbar disc herniation.
The maintenance of physiological lordosis allows the column stabilizer muscles to perform their work and thus prevent any damage, especially during the lifting of loads .
Avoid sedentary lifestyle
The loss of lordosis is evident above all in people who perform sedentary work in a sitting position . In fact, in this position we tend to lose the optimal posture by bringing the pelvis in retroversion with a consequent loss of the lumbar curve .
In fact, many studies show that the maximum load at the level of the intervertebral discs is reached precisely in the sitting position, another factor that weighs on the increased risk of a herniated disc . Furthermore, if we add to these two factors the shortening of the aforementioned muscles due to a static position maintained over time, we have the perfect recipe to start damaging our back.
So moderate physical activity combined with general strengthening exercises is of fundamental importance, focusing in particular on the abdominal and lumbar area.
Abdominals and herniated disc
The training of the abdominal area aims to stabilize the lumbar spine and manage intra-abdominal pressures. The abdominal muscles , together with the lumbar one, give life to what we call core .
The usefulness of strengthening the abdomen is therefore not limited to avoiding symptomatic relapses in the case of a herniated disc but plays a fundamental role in the prevention of injuries.
Each person could benefit from the training of the core area , in particular people with previous low back problems and especially people who perform sedentary work.
How to train with a herniated disc
Can I train in the gym with a herniated disc ? It is a question that is almost impossible to answer without analyzing the single clinical case. Basically the answer is yes. Symptomatology is certainly a discriminating factor. In fact, during the acute phase it is obviously not recommended to train because nobody can think of squats with pain and paresthesia in the legs.
As reported above, the percentage of subjects in which a protusion to the instrumental examination is evident can reach 40%, even without symptoms. But, if we add to this percentage the age-related disc degeneration it goes over 50%.
However, a protusion or herniated disc should not scare and above all should not be experienced as a limit for the rest of life, precisely because, referring to the statistics, it is very likely that other people are training despite having the same problems but without a diagnosis or symptoms.
However, it is appropriate, once the acute phase is over, to put oneself in the hands of a human movement professional. In fact, the risk of recurrence is always present but, above all, the risk of compromising other intervertebral discs by performing incorrect and repeated movements.
In addition, a beginner or otherwise a non-sports person will approach the gym with the goal of post-hernia recovery . Therefore, he will not have competitive ambitions and will have no pre-injury performance to deal with.
Herniated disc and body building
Instead, the bodybuilder or weight lifter comes with a wealth of experience and is accustomed to working with very high loads and intensities. But, also in this case, a progressive re-athleticization is fundamental . The psychological factor plays a key role.
To conclude, the herniated disc is absolutely not to be underestimated but it is also not necessary to leave the gym. Psychological terrorism practiced by non-professionals is on the agenda, for this reason you have to rely on a professional.
Exercises to do and those to avoid
However, there are some guidelines on exercises considered “dangerous” in case of hernia in the asymptomatic phase of the herniated disc.
Generally speaking it is possible to say that exercises such as deadlift and squats, with all their variations, must be managed in the best way. Their danger is not found in the exercise itself but in the errors that can be made during the execution. In fact, a poor muscle tone, especially of the abdominal muscles , associated with an incorrect technique can actually lead to a significant increase in risk.
For example, in the deadlift , the initial phase with the push of the legs and the trajectory of the barbell are fundamental.
To respect these two precautions it will be necessary to perform the movement with an impeccable technique. The squat may be technically simpler , but this exercise also hides possible pitfalls. In fact, the final phase of the movement is influenced by the mobility of the hips and ankles, therefore it is necessary to evaluate the optimal (subjective) range of movement to avoid a loss of the correct technique.
In both exercises, as in all weight lifting , maintaining the lumbar curve is essential to avoid further injuries or relapses.
Is a containment belt useful?
The time has come to dispel a myth . The lumbar support belt does not prevent back pain , on the contrary it is even counterproductive in cases where the muscle tone of the abdominal and lumbar area is poor.
A reinforcement of the core area is the best solution in the long term and to avoid recurrence.
The lumbar support belt is used very often incorrectly even in the gym.
The real function of the lumbar belt in weightlifting is to increase the lumbar pressure and thus stabilize the lumbar spine preventing injuries. But in order to perform its supporting function, the belt must be very tight in order to exert strong mechanical pressure in the core area .
The lumbar belt is therefore useful in exercises such as deadlift, squats (and variants) and some rowing exercises with loads close to the ceiling. Instead, in medium-low loads it could be counterproductive because it would not allow the body to activate the stabilizing muscles of the column and therefore would increase the risk of injuries due to muscle imbalances.
While the use of the lumbar belt for all other exercises is in fact useless.
Disc herniation: prevention
Prevention, as in the vast majority of pathologies, plays a key role. Although the herniated disc often has a basic genetic component, it can still benefit from all types of prevention. Reducing the risk of being affected by a herniated disc, reducing recovery times and above all maintaining a good quality of life in the period following the resolution of the problem .
An effective muscle structure and good elasticity are the fundamental points to be satisfied in the prevention of the herniated disc because the intervertebral disc takes on all the forces passing through the spine.
To support this onerous work there are a series of structures including ligaments that provide “passive” support and muscles that actively support the structure. In the vicinity of the vertebrae, and therefore of the intervertebral disc, there are a series of muscles assigned to the extension of the trunk and which have a postural function. They are all the deep muscles of the back that originate from the head and neck , travel the entire length of the vertebral column and are inserted in the lumbar and sacral area.
In synergy with these long and tireless muscles, other smaller muscles work but with important functions in maintaining the stability of the spine. With two simple examples we have highlighted how much muscle tone can affect the spine. However, the contribution of the skeletal muscle system does not stop there.
Regular physical activity is part of the healthy lifestyle that we should all follow, not just to prevent herniated discs.
For example, smoking is a risk factor for disc degeneration. Damaging the microcirculation of the intervertebral disc will lead to a worsening of the local circulation and a consequent degeneration of the disc tissues and adjacent areas.
Even sleep is an important factor in the health of your back . In fact, during the day, particularly in the sitting position, the intervertebral disc tends to dehydrate due to the continuous load on it. The lying position taken during sleep is also valuable for the discs. In fact, it is during the night’s rest that the disc rehydrates and fully recovers its functions. Hence, insufficient hours of sleep can lead to complete disc rehydration and future back problems.
Nutrition also plays a key role in prevention. Proper nutrition generates a cascade of healthy related habits.
For this reason, following a balanced diet is perhaps the most difficult of all because it involves a substantial change in daily habits, but it remains the best weapon of prevention when combined with physical activity .
Disc herniation and overweight
Recent studies have shown a correlation between excessive body weight and non-specific low back pain, therefore an increase in herniated disc has been recorded among the obese. But, the only overweight cannot be defined as the only trigger of the pathology, the wrong lifestyle, leads to a series of consequences on the state of health, including overweight.
So it is common ground that an incorrect lifestyle causes an increased risk of herniated discs and being overweight is one of the “alarm bells” of a person’s health . In conclusion, the control of body weight can influence, it is assumed indirectly, the risk of developing pathologies of the vertebral column, like the herniated disc.
How to lift weights
Although some studies do not show concrete differences between lifting a weight correctly (bent legs and straight back) and incorrect (stretched legs, flexed back) it is strongly recommended to learn how to protect your back during every type of movement .
Furthermore, when lifting loads, the advice is to avoid reaching the weight with the legs stretched and then pull it up by extending only the back. The ideal movement involves bending the legs , maintaining physiological lordosis of the back and lifting the weight by extending the legs and only later on the torso.
For example, the witch’s blow is a classic case. It usually affects people who hold a flexed position for a long time, such as washing the floor. In fact, during the flexion the pressure on the front of the disc increases, the core is then pushed posteriorly and if to the protracted flexion we associate a sudden extension we take the structures by surprise. These are not able to adapt quickly to the new stimulus leading to a possible blockage of the back and excruciating pain , the witch’s blow.
Particular attention should also be paid to movements considered “stressful” for the intervertebral disc. These include all the torsional movements of the torso, especially those performed in a sitting position.