Herniated Discs

1. Herniated Discs By Michael LaBella

2. Objectives • You will be able to identify the anatomy of the lower back • You will understand the types of trauma that can cause a herniated disc • You will be able to identify the signs of a herniated disc • You will be able to evaluate athletes with potential herniated discs • You will be able to follow a typical treatment program for herniated discs

3. Anatomy • Vertebral column (spin) consists of 33 vertebrae • Spine is divided into thoracic, lumber, cervical • Each section of spine containing 5-12 vertebrae • We will be focusing on the lower back or lumbar region

4. Lumbar Anatomy • The lumbar section of the spine is made up of the lower 5 vertebrae • Commonly referred to as L1 to L5 • L5 connects to the top of the sacrum

5. Anatomy of Lumbar Verebra • The vertebral body is a thin ring of dense bone • Consisting of the body, pedicles and liminae • Vertebral foramen is a whole in vertebral body that spinal cord runs through

6. Intervertebral Discs • Gel like Tissue between each vertebra • fibro cartilaginous cushions • serve as the spine's shock absorbing system • protect the vertebrae, brain, and other structures • The discs allow some vertebral motion extension and flexion.

7. Intervertebral Discs • The disc is made up of 3 structures the • (1) Nucleus pulposus, gelatinous center • (2) Annulus Fibrosus. Its job is to contain the nucleus • (3) Vertebral end plates that attach the disc to the vertebrae

8. Herniated disk • Can Occur when there is enough pressure from the vertebrae above and below • This can force some or all of the nucleus pulposus through a weakened or torn part of the annulus fibrosus.

9. The ruptured nucleus will often come incontact with and press on nerves near the disc. • This can result in severe pain • About 90% of herniated discs occur in the lumbar region. The discs in the cervical region are affected about 8%, those of the thoracic region only about 1-2% • Herniated disks are one of the most common causes of back pain

10. Mechanism of injury • There are 3 main ways discs can become herniated of ruptured • Many older people get herniated disks because the disks have worn down over time • The extremely overweight are very susceptible because they are carrying around excess weight which puts extra pressure on the intervertebral disks • Improper lifting form, usually associated with bending with back and not with knees. Which can cause a sudden strain. This can be everyday lifting of objects or actual weight training • Twisting violently can also cause a sudden strain that could possible herniate a disk

11. Recognition • How can we as coaches recognize a herniated disk? • Sharp and shooting pain the runs down athletes low back, buttocks and down the thigh • If the athlete complains of numbness or tingling anywhere in lower back, buttocks or leg • If athlete complains pain gets worse after any kind of strain to the body • Sometimes, the disk can pinch the nerve controlling bladder functioning

12. Evaluation • The first thing a coach should ask his athlete, would be the history of the injury; if the athlete felt the pain immediately after performing a heavy deadlift at the gym that would be a good indicator of a herniated disk • The coach should also ask athlete where the pain is, sciatica is very typical with herniated disks

13. Doctors Evaluation • A coach can never be 100% sure, so the athlete must be sent to a doctor to perform an MRI (magnetic resonance imaging) or a CT (computerized tomography) • An MRI is the best choice because it can clearly show the bones nerves and disks that might be damaged

14. Treatment • The first thing that should be done is to rest and stay away from activity the agitate the symptoms • Then the application of ice and heat • This acts to relax the muscles in the back which can calm pain and any muscle spasms

15. Treatment • Physical Therapy • Although performing physical Therapy does not directly help the disks, it does strengthen the muscles around it, so as to increase stability, which can help prevent herniated disks in the future

16. Treatment • Pain relievers are often given to patient to alleviate pain • Anti-inflammatory drugs are given to reduce swelling • Although not all patients report having back pain

17. Physical Therapy Exercises • Exercise #1 while lying on your back bend your left knee up. Clench abs and butt, keeping back in neutral position. • Raise your other leg about 12in off floor, while knee is straight • Hold the position for 3 seconds • Then lower leg, do for 10 reps • Repeat the same with your other leg

18. Physical Therapy Exercises • Exercise #2 Start with both knees on floor, clench abs and butt, back is straight • Put your hands on your hips. • Pickup your right foot and place on floor in front of you, while your left knee is still on floor • Lunge forward,. • Hold your position for 3-5 seconds • Return your right knee to floor • Do for 10 reps • Then repeat with the other leg

19. Surgery • Surgery is very rarely required for herniated disks • The treatment previously described is almost always done prior to surgery • Generally if symptoms, such as pain and numbness grow worse over time surgery is required • If herniated disk interferes with bladder and bowl movements, surgery is also required

20. Rehabilitation • Herniated disks can vary in severity and the rehabilitation plan can vary depending on the severity of the symptoms; • Phase #1 Rest- This can last from 2 days up to 2 months depending on the nature of the injury, typically the older the patient the longer the rest period. As stated before, rest should include immobilization of spinal column as well as icing and heating of the lower back

21. Rehabilitation • Phase #2 After symptoms have subsided, anywhere from 10days to a few months exercises should be done to strengthen muscles around spinal column to help prevent another hernia. Doctors clearance is preferred so as not to begin exercises to early, which could cause a re injury. These exercises may be done with some slight lower back pain

22. Rehabilitation • Hamstring stretch • Lay down face up with one leg in door way other leg on wall • This stretches out ligaments and tendons that connect from leg to lower back

23. Rehabilitation • Cat and Camel • On your hand and knees, allow your back to sag for 5 seconds, then arch your back for 5 seconds • Repeat for 10 reps

24. Rehabilitation • Arm/Leg Raise • On your hands and knees • Tighten abs so spinal column is stiff • Raise right arm and left leg as shown to the right • Do 10 reps and switch arm/leg

25. Rehabilitation • After all pain has gone the following exercise may be performed • Partial curl-lying on your back with knees bent and feet on floor • Tuck the chin into the chest • Curl upper body forward intill your shoulder blades are off the floor • Hold the position for 3 seconds and repeat for 10 reps

26. Return to play • In order for an athlete that has sustained a herniated disk to return to play he/she must have clearance from their doctor • This will not usually happen until all pain, and numbness has gone completely

27. Prevention • The stretches and exercises listed previously can strengthen the muscles around the discs, which can increase the stability of the discs • Teaching and practicing proper lifting form is essential in preventing these injuries

28. References • Cassisi, J. E. Ph.D.; Sypert, G. W. M.D.; Laganá, L. Ph.D.; Friedman, E. M. B.A.; Robinson, M. E. Ph.D. Pain, Disability, and Psychological Functioning in Chronic Low Back Pain Subgroups: Myofascial versus Herniated Disc Syndrome. American J. of Phy. Med. And Rehab. Volume 33(3), September 1993, p 379–386 • Ito, T. MD; Takano, Y. MD and; Yuasa, N. MD. Types of Lumbar Herniated Disc and Clinical Course. Clinical J. of Pain. Volume 26(6), 15 March 2001, pp 648-651 • Vucetic, N. MD, PhD; Astrand, P. MD, PhD; Guntner, P. MD; Svensson, O. MD, PhD Diagnosis and Prognosis in Lumbar Disc Herniation. Clinical Orthopaedics & Related Research. 361:116-122, April 1999. • http://www.mayoclinic.com/health/herniated-disk/HD99999 • http://www.neurosurgerytoday.org/what/patient_e/herniated.asp