Causes of bulging lumbar discs



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The vertebrae are individual bones that form the spine.

Between each of the anterior part of the vertebrae are the discs. Ligaments support the spine and discs. The spine has seven vertebrae in the neck (cervical vertebrae), twelve vertebrae in the mid-back (thoracic vertebrae), and five vertebrae in the low back (lumbar vertebrae).

The bony spine is designed so that vertebrae "stacked" together can provide a flexible stable structure while also protecting the spinal cord that extends down a central canal in the spinal column from the brain. Each vertebrae has a spinous process, which is a bony prominence behind the spinal cord that protects the cord. The vertebrae also have a prominent bony front to provide protection for the spinal cord as well as to provide support for the spine.

The discs are cushions that serve as "pads" between each vertebral body. The discs minimize the impact of movement on the spinal column. Each disc consists of a central soft component (nucleus pulposus). This soft component can rupture (herniate) through the tougher outer ring (annulus fibrosus) and irritate nearby nerves. Ligaments are strong fibrous bands that attach bones to bones. Ligaments are attached to the vertebrae and surround each of the discs. Ligament injury can resultr as the disc degenerates.

With aging, the intervertebral disc may lose water content and become dried out. As this happens, the disc compresses. This may lead to deterioration of the tough outer ring allowing the nucleus to bulge out. This is called a bulging disc.

As the disc continues to degenerate, the inner nucleus pulposus may rupture out from the annulus. This is called a herniated disc. The fragments of disc material press on nerve roots located just behind the disc. This causes pain, weakness, and numbness.

Most disc herniations happen in the lower lumbar spine, particularly at the L4-5 and L5-S1 levels. Most of the time, disc disease comes as a result of aging and the degeneration that occurs within the disc. Trauma may also cause an already damaged disc to get worse. Most often, discs herniate because of injury or improper lifting, but aging plays a pivotal role. With age, the discs dry out and become harder. The tough fibrous outer wall of the disc, or annulus, may weaken, and it may no longer be able to hold the gel-like substance in the center. This material may push out through a weakness in the disc wall, causing pain when it touches a nerve. Genetics, smoking, and a number of occupational and recreational activities may lead to early disc degeneration.

Because both the discs and the joints that stack the vertebrae (facet joints) are composed of cartilage, these areas undergo wear and tear with age. The gradual deterioration of the disc between the vertebrae is referred to as degenerative disc disease.

Degeneration of the disc is medically referred to as spondylosis. Spondylosis can be noted on x-ray tests or MRI scanning of the spine as a narrowing of the normal disc space between adjacent vertebrae.

Degeneration of the disc can cause local pain in the affected area. Any level of the spine can be affected by disc degeneration. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized back pain. The pain from degenerative disc or joint disease of the spine is treated conservatively with heat, rest, physical therapy, and medications to relieve pain, muscle spasm, and inflammation.

Radiculopathy refers to nerve irritation caused by damage to the disc between the vertebrae. Weakness of the outer ring because of degeneration or trauma leads to disc bulging and herniation. As a result, the central softer portion of the disc can rupture through the outer ring of the disc and put pressure on the spinal cord or its nerves as they exit the bony spinal column.

When nerves are irritated in the low back from degenerative disc disease, the condition is called lumbar radiculopathy. This presents as "sciatica" pain that shoots down the leg. Sciatica pain can occur coincident with a "popping" sensation and be accompanied by numbness and tingling. The pain commonly increases with movement and also can increase with coughing or sneezing. In more severe instances, lumbar radiculopathy can be accompanied by bowel and/or bladder incontinence.

The diagnosis is made through history and physical examination. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) can be used to detect nerve irritation or damage. Disc herniation can be detected with CAT or MRI scanning.

The treatment of radiculopathy ranges from nonsurgical (medical) management to surgery. Medical management of radiculopathy includes patient education, medications, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage, ultrasound, electrical stimulation), and rest. With severe pain or progressive neurologic deterioration, surgery may be necessary. The operation performed depends on the overall status of the spine, and the age and health of the patient.



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