Posterior Disc Bulge Between T12 – L1 – Diagnosis, Treatment

Posterior Disc Bulge Between T12 – L1/Posterior disc bulging is one of the most leading common causes of PLID, lumbar intervertebral discs disorders, epidural hematoma, epidural abscess, spinal cord infarction, discal cyst, mechanical back pain, degenerative spinal stenosis degenerative cervical spondylosis, cauda equina syndrome, and spinal mechanical derangements of the low back in patients suffering from intractable sciatic pain, herniation disc. The leg pain is due to direct pressure of the displaced intervertebral disc tissue on one or more roots of the cauda equina. In addition to this lesion, there may be found associated thickening of the ligamentum flavum, chronic adhesive arachnoiditis, hypermobility of the involved vertebrae, and edema of the involved nerve roots. Although the etiology of posterior disc protrusions is not perfectly clear, trauma to and degenerative changes in the intervertebral discs alone or in combination seem to be the usual causes of posterior protrusion.

A posterior disc bulging represents the displacement of the outer fibers of the annulus fibrosus beyond the margins of the adjacent vertebral bodies, involving more than one-quarter (25% or 90 degrees) of the circumference of an intervertebral disc. Because it is limited by the annulus fibrosus it does not extend above or below the attached margins of the disc. Disc bulges, along with vertebral endplate bowing, are responsible for the disc height loss that is seen with aging.

Types of Bulging Discs

Bulges are always broad, and can be further divided according to how much of the circumference they involve

• Circumferential bulge – involves the entire disc circumference
• Asymmetric bulge – does not involve the entire circumference, but nonetheless more than 90 degrees

Bulging discs can also be classified by the area of the disc they protrude into (herniation zone).

• Central – When the disc extrudes into the spinal cord.
• Subarticular (Lateral Recess or Paracentral) – When the disc extrudes between the spinal cord and the foramen (space through which the nerves exit the spinal canal).
• Foraminal (Lateral) – Disc extrusion into the foramen.
• Extraforaminal (Far Lateral) – Disc extrusion beyond the foramen.

Anatomy of the Lumbar Spine

The vertebral column, also called the backbone, is made up of 33 vertebrae that are separated by spongy disks and classified into four distinct areas. The cervical area consists of seven bony parts in the neck; the thoracic spine consists of 12 bony parts in the back area; the lumbar spine consists of five bony segments in the lower back area; five sacral bones (fused into one bone, the sacrum); and four coccygeal bones (fused into one bone, the coccyx).

Lumbar posterior disc bulging occurs in the lumbar area of the spine. The lumbar area of the spine (and other areas of the spine) is made up of two parts, including the following:

• Vertebral bodies –The parts that are made of bone.
• Intervertebral disks (also known as the disks) – The disks are located between the bony parts of the spine and act as “shock absorbers” for the spine.

The vertebral bodies are numbered from 1 to 5 in the lumbar spine and the disks are located between two of the vertebral bodies and are numbered accordingly (such as a disk at L2-3, or between the lumbar disks numbered 2 and 3). The intervertebral disk is composed of two parts, including the following:

• The annulus fibrosis – A tough outer ring of fibrous tissue.
• Nucleus pulposus – Located inside the annulus fibrosis; a more gelatinous or soft material.

Causes for Posterior Disc Bulge Between T12 – L1

• Repetitive trauma – such as poor posture, poor ergonomics, or repetitive heavy work can lead to disc degeneration and a posterior disc bulging. These long-term injuries are often also associated with poor muscle strength, obesity, and other factors such as smoking.
• An Injury caused – by sudden forces or load on the disc such as a car accident or an awkward heavy lift. This sudden increase in pressure on the disc can cause damage and tears to the annulus that causes a posterior disc bulging.
• Spinal Degeneration – While some degeneration is a normal part of the aging process, poor spinal function and posture will dramatically speed up disc degeneration with a posterior disc bulging.
• People who have led a sedentary lifestyle or those who smoke – increase the chances for bulging disc and posterior disc bulging.
• Continuous strain on the disc from injury or heavy lifting – and strain can wear them down throughout the years and may lead to posterior disc bulging.
• Weakened back muscles – can accelerate the process and may lead to a sudden herniation of the weakened disc.
• Although bulging discs occur over time, herniated discs may occur quickly by trauma with posterior disc bulging.
• Bad posture – including improper body positioning during sleep, sitting, standing, or exercise are all risk factors that may contribute to the development of a bulging disc.
• Obesity
• High contact sports or activities – are also risk factors.
• Runners who fail to use shoes that provide orthopedic support – may also develop bulging discs.
• Activities that place stress and strain on the spine – can lead to the weakening of the sposterior disc bulging.
• Mechanical back pain
• Muscle strain
• Osteophytes
• Spondylolisthesis
• Degenerative spinal stenosis
• Cauda equina syndrome
• Epidural abscess
• Epidural hematoma
• Diabetic amyotrophy
• Metastasis
• Ankylosing spondylitis
• Synovial cyst
• Neurinoma

Daily Unconscious lifestyle that may lead to disc bulging

• Vehicle accident
• Already existing annulus weakness
• Body mechanics and poor posture put stress on the spinal disc
• Torsion of the disc from repetitive work with a lot of bending, twisting or lifting
• Sitting, standing driving or working for long periods of time
• Sustaining back injury from a severe fall
• Repetitive forceful motions in certain sports
• Poor heavy lifting techniques, like bending forward to pull with your back can put sudden excessive load on the disc
• Abdominal fat and poor core stability
• Reduced lower limb strength.
• People genetically predisposed to have a lesser density of fibrocartilaginous fibers that make up the disc.

Symptoms of Posterior Disc Bulge Between T12 – L1

If a  posterior disc bulging has not yet reached the stage of herniation, a patient may have little to no pain involved. A bulging disc may have no pain at all because it has not reached a certain severity level, and this can make it difficult to identify the bulging disc symptoms before the condition becomes more severe.

Most commonly, posterior disc bulging creates pressure points on nearby nerves which create a variety of sensations. Evidence of a posterior disc bulging may range from mild tingling and numbness to moderate or severe pain, depending on the severity. In most cases, when a bulging disc has reached this stage it is near or at herniation.

• Tingling or pain in the fingers, hands, arms, neck, or shoulders – This could indicate a bulging disc in the cervical area.
• Pain in the feet, thighs, lower spine, and buttocks – This is the most common symptom and could indicate an issue in the lumbar region.
• Difficulty walking or feeling of impairment while lifting or holding things.
• Loss of Bladder or Bowel Function – There are some bulging disc cases where professional care is essential. In some cases, such as when you lose bowel or bladder control, it is deemed an emergency, and you may require immediate surgery. These bulges usually are very significant and affect your nerve control involving your bladder or bowels. You should go straight to your nearest emergency department in these instances.
• Weakness in your limb muscles – is a significant concern. If you experience arm, hand, leg or foot weakness, please seek prompt medical assessment.
• The reduced or altered sensation – is your next priority. Mild disc bulges can reduce your ability to feel things touching you, e.g. numbness or pins and needles. If you experience any of the above symptoms, you should seek professional assistance.
• Referred Pain – Pain in your limbs, e.g. legs (sciatica) or arms (brachialgia) is usually a more significant injury than when experiencing only spinal pain. We recommend that you seek the professional advice of your trusted spinal care practitioner.
• Spinal Pain – Interestingly, if you are only experiencing spinal pain, bulging discs are generally mild injuries and the most likely to rehabilitate quickly. Please adhere to low disc pressure postures and exercise accordingly. If in doubt, please seek professional advice.
• Intermittent or continuous back pain. This may be made worse by movement, coughing, sneezing, or standing for long periods of time.
• Spasm of the back muscles
• Sciatica. Pain that starts near the back or buttock and travels down the leg to the calf or into the foot.
• Muscle weakness in the legs
• Numbness in the leg or foot
• Decreased reflexes at the knee or ankle
• Changes in bladder or bowel function
• Radicular pain
• Sensory abnormalities at the lumbosacral nerve roots distribution
• Weakness at the lumbosacral nerve roots distribution
• Limited trunk flexion
• Pain exacerbation with straining, coughing, and sneezing
• The pain intensified in a seated position, as the pressure applied to the nerve root is increased by approximately

Associate clinical feature is

• Severe back pain
• Saddle anesthesia i.e., anesthesia or paraesthesia involving S3 to S5 dermatomes, including the perineum, external genitalia, and anus; or more descriptively, numbness or “pins-and-needles” sensations of the groin and inner thighs which would contact a saddle when riding a horse.
• Bladder and bowel dysfunction, caused by a decreased tone of the urinary and anal sphincters.
• Detrusor weaknesses causing urinary retention and post-void residual incontinence as assessed by bladder scanning the patient after the patient has urinated.
• Sciatica type pain on one side or both sides, although pain may be wholly absent
• The weakness of the muscles of the lower legs (often paraplegia)
• Pain in one leg (unilateral) or both legs (bilateral) that starts in the buttocks and travels down the back of the thighs and legs (sciatica)
• Numbness in the groin or area of contact if sitting on a saddle (perineal or saddle paresthesia)
• Bowel and bladder disturbances
• Lower extremity muscle weakness and loss of sensations
• Inability to urinate (urinary retention)
• Difficulty initiating urination (urinary hesitancy)
• The decreased sensation when urinating (decreased urethral sensation)
• Inability to stop or control urination (incontinence)
• Reduced or absent lower extremity reflexes
• Local pain is generally a deep, aching pain resulting from soft tissue and vertebral body irritation.
• Leg pain (radicular pain) is generally a sharp, stabbing pain resulting from compression of the nerve roots.
• Radicular pain projects along with the specific areas controlled by the compressed nerve (known as a dermatomal distribution).
• Inability to stop or feel a bowel movement (incontinence)
• Constipation
• Loss of anal tone and sensation
• Achilles (ankle) reflex absent on both sides.
• Sexual dysfunction
• Absent anal reflex and bulbocavernosus reflex
• Gait disturbance

These symptoms require immediate medical evaluation as they may be a sign of a potentially life-threatening condition.

Diagnosis of Posterior Disc Bulge Between T12 – L1

History

• History in these patients should include the chief complaint, onset of symptoms, alleviating and aggravating factors, radicular symptoms, and any past treatments. The most common subjective complaints are axial neck pain and ipsilateral arm pain or paresthesias in the associated dermatomal distribution.

Physical Examination

• A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location, and reflex loss associated with the different levels are described above. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities.  Typical findings of solitary nerve lesion due to compression by a herniated disc with bulging in the lumbar spine

Typical findings of solitary nerve lesion due to compression by a herniated disc in the cervical spine

• C5 Nerve – neck, shoulder, and scapula pain, lateral arm numbness, and weakness during shoulder abduction, external rotation, elbow flexion, and forearm supination. The reflexes affected are the biceps and brachioradialis.
• C6 Nerve – neck, shoulder, scapula, and lateral arm, forearm, and hand pain, along with lateral forearm, thumb, and index finger numbness. Weakness during shoulder abduction, external rotation, elbow flexion, and forearm supination and pronation is common. The reflexes affected are the biceps and brachioradialis.
• C7 Nerve – neck, shoulder, middle finger pain are standard, along with the index, middle finger, and palm numbness. Weakness on the elbow and wrist are common, along with weakness during radial extension, forearm pronation, and wrist flexion may occur. The reflex affected is the triceps.
• C8 Nerve – neck, shoulder, and medial forearm pain, with numbness on the medial forearm and medial hand. Weakness is common during finger extension, wrist (ulnar) extension, distal finger flexion, extension, abduction, and adduction, along with distal thumb flexion. No reflexes are affected.
• T1 Nerve – pain is common in the neck, medial arm, and forearm, whereas numbness is common on the anterior arm and medial forearm. Weakness can occur during thumb abduction, distal thumb flexion, and finger abduction, and adduction. No reflexes are affected.
• L1 Nerve – pain and sensory loss are common in the inguinal region. Hip flexion weakness is rare, and no stretch reflex is affected.
• L2-L3-L4 Nerves  – back pain radiating into the anterior thigh and medial lower leg; sensory loss to the anterior thigh and sometimes medial lower leg; hip flexion and adduction weakness, knee extension weakness; decreased patellar reflex.
• L5 Nerve – back, radiating into buttock, lateral thigh, lateral calf and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex.
• S1 Nerve – back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.
• S2-S4 Nerves – sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.

A physical exam for diagnosing disc pain may include one or more of the following tests

• Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc.
• Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a lumbar herniated disc (straight leg raise test).
• Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by a herniated disc. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
• Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine.

Special Manual Tests

Neck Pain Maneuvers

• Spurling’s maneuver – By turning your head and gently applying pressure, your doctor may reproduce radiating, nerve-related neck pain.
• Manual neck distraction test – This test will help identify nerve pain in your neck. Your doctor will ask you to lift your head, which may relieve pressure on compressed nerves.

Low Back And Leg Pain Maneuvers

• Femoral stretch test – While lying face down, your doctor will flex each knee to determine if you feel pain in your thigh. If you do, this indicates nerve compression in your lumbar spine.
• Schober test – This test examines the range of motion in your lumbar spine. During this test, you will bend over, as if you are trying to touch your toes.
• Trendelenburg test – This test can identify weakness in the muscles that support the hip. In this test, you’ll stand straight on one leg for 30 seconds. Your doctor will observe if your pelvis stays level.

Provocative Tests In A Spinal Examination

• Shoulder Abduction (Relief) sign – Active abduction of symptomatic arm achieved by patient placing their ipsilateral hand on their head. A positive test results in relief (or reduction) of cervical radicular symptoms.
• Neck Distraction test – Active distractive force is applied by the examiner while grasping the patient’s head under the occiput and chin. A positive test results in relief (or reduction) of cervical radicular symptoms.
• L’hermitte’s sign – Examiner passively flexes patient’s cervical spine. A positive test result is an electric shock-like sensation down the spine or extremities.
• Hoffman’s sign – Passive snapping flexion of distal phalanx of patient’s middle finger. A positive test results in flexion-adduction of the ipsilateral thumb and index finger.
• Adson’s test – Patient is instructed to inspire with chin elevated, and head rotated to the affected side. A positive test results in obliteration of radial pulse.
• The Spurling test – is designed to reproduce symptoms by compression of the affected nerve root. The cervical extension is used to induce/reproduce posterior bulging of the intervertebral disk. Rotation of the head causes narrowing of the neuroforamina in the cervical spine. Finally, axial compression is applied to amplify these effects with the aim of exaggerating the preexisting nerve root compression.
• The prone instability test – The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso onto the couch.  The patient can hold onto the couch’s sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine, while the feet are off the floor, is considered positive. [rx]
• Prone Plank/Bridge – The patient is prone and elevates his / her entire body off the couch/mat on forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.[rx]
• Supine Bridge – The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- the 30s. [rx]

Clinical Tests For Instability

• Aberrant movement on flexion-extension – The standard examination involves documenting the range of movement. The quantitative range of movement may not be as significant as the qualitative range of movement. The important feature of spinal instability is the aberrant motion that occurs when flexing and extending the spine. A catch, a painful arc, supporting the arms on the thighs, or a reversal of the lumbopelvic rhythm when standing from the flexed posture indicates instability.[rx]
• Passive lumbar extension test – The subject lies on the examination couch. The examiner passively lifts the lower limbs to a height of 30 cm from the coach while maintaining the knee in extension and applying gentle traction on the legs. A positive test is recorded if the patient complains of “pain in the lower back region” or complains of “heaviness in the lower back” or complains that, “the lower back is coming off.” These experiences should return to normal when the leg returned to the couch. The passive lumbar extension test has the highest combined sensitivity and specificity and may be comparable to radiological findings to identify lumbosacral structural instability.[rx]
• The prone instability test – The patient stands at the foot end of the examination couch. The patient then lowers his/her upper body to rest on the examination couch. The iliac crest should rest on the edge of the examination couch. The patient holds the sides of the examination couch for increased stability. In the first part of the test, the feet of the patient are resting on the ground. The examiner with the heel of his/her hand creates a small posterior to anterior trust at each segment of the lumbar spine. Pain, if experienced by the patient, is recorded. In the second part of the test, the patient is asked to lift the feet of the floor and steady himself /herself by holding onto the sides of the examination couch. The examiner again repeats the posterior to anterior trust with the heel of his/her hand at each lumbar segment. The test is positive if the pain created in the initial part of the test subsides when the extensor muscles of the spine are tensed by lifting the feet of the floor.[rx]

Clinical Tests For Endurance

• Sorensen test – The legs of the patient are strapped onto a low platform, which is only 25 cms above the floor.  The upper end of the iliac crest is aligned to the edge of the table. The upper torso rests on the floor. At the commencement of the test, the patient extends the spine and lifts the upper torso off the floor with the arms crossed across the chest, and is asked to maintain the horizontal position. The record of the time, the patient can maintain this position is documented.  Normative values: Men 146 +/- 51. Women 189 +/- 60.[rx]
• Prone isometric chest raise – The patient lies prone on the examination couch with a pad underneath the abdomen and the arms along the sides. The patient is instructed to lift the upper trunk about 30 degrees from the table while keeping the neck flexed, and the intention is to hold the sternum of the surface of the couch. The clinician records the maximum time that the patient can hold this position. [rx]Normative values: Men 40 +/- 9. Women 52 +/- 18.[rx]
• Prone double straight leg raise – The patient lies prone on the examination couch with the hips extended and the hands underneath the forehead. The arms are perpendicular to the body. The patient is then requested to lift both the legs off the couch until the knee is cleared off the couch. The patient should maintain normal breathing during the entire test procedure. The examiner can monitor the knee clearance by sliding a hand under the knee. The clinician records the maximum time that the patient can hold this position. Normative values: Men 38 +/- 6. Women 35 +/- 5. The prone double straight leg raise has shown to have great sensitivity and specificity. [rx]
• Supine static chest raise – The patient lies supine on the couch with the legs extended. The hands are placed on the temples with the elbows pointing to the ceiling.  The patient is then instructed to lift the head, the arms and the upper trunk of the couch. The patient should maintain normal breathing during the entire test procedure. The clinician records the maximum time that the patient can hold this position. Normative values: Men 43 +/- 9. Women 32 +/- 5. [rx]
• Supine double straight leg raise – The patient lies supine with the legs extended, and the arms crossed in front of the chest. The pelvis is tilted forward to increase the lumbar lordosis. The patient is then requested to lift both the legs of the floor for 30 degrees while maintaining normal breathing during the entire test procedure. To monitor the pelvic tilt, the examiner can place one hand under the lumbar spine.  The clinician records the maximum time that the patient can hold this position. Normative values: Men 28 +/- 4. Women 28 +/- 4. [rx]
• Flexor endurance test – The patient is supine on the couch with the upper part of the body propped up on a support. The support is at an angle of 60 degrees. The legs are flexed so that the knee is at a 90-degree angle with the foot flat on the couch. The toes and feet are strapped to the couch to provide a counterbalance. In a modified procedure, the examiner sits on the edge of the couch and over the toes of the patient to provide a counterbalance. The arms are crossed across the chest towards the opposite shoulder. The support is moved back by 10 cms, and the patient is instructed to maintain the original position. The clinician records the maximum time that the patient can hold this position. Normal values: Men 144 +/- 76, Women 149 +/- 99 in normal subjects.[rx]
• Prone Plank/Bridge – The patient lies prone on a mat. Initially, the patient lifts his / her upper torso off the mat and steadies on the elbows and forearms. The elbow is directly below the shoulder, and the forearms are straight with hands in front of the elbow. The patient then lifts the pelvis off the mat. The body is now supported on the elbow/forearm and the tips of the toes. The patient maintains a rigid horizontal position parallel to the floor. The clinician records the maximum time that the patient can hold this position. Normative values: Men 124 +/- 72s, Women 83 +/- 63s.[rx]
• Supine Bridge – The patient lies supine with the legs flexed so that the knee is at a 90-degree angle, and the foot is flat on the couch but not touching each other. The elbows are bent, and the hands are placed on the ears. The patient then lifts the pelvis so that the shoulders, hips, and knees are in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 188 +/- 45s, Women 152 +/- 30s.[rx]
• Side Plank/Bridge – The patient lies on the side of a mat. The upper part of the body is lifted off the mat and supported on the elbow of the arm below. The opposite (upper) arm crosses across the chest onto the lower shoulder. The top foot is positioned in front of the lower foot. The patient is then instructed to lift the pelvis off the floor and to maintain the trunk and the legs in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 95 +/- 35s, Women 74 +/- 33s.[rx]

Waddell Signs Include

• Superficial tenderness – The patient’s skin over a wide area of the lumbar skin is tender to light touch or pinch.
• Non-anatomical tenderness – The patient experiences deep tenderness over a wide area that is not localized to one structure and crosses over non-anatomical boundaries.
• Axial loading – Downward pressure on the top of the patient’s head elicits lumbar pain.
• Acetabular rotation – Lumbar pain is elicited while the provider passively and simultaneously externally rotates the patient’s shoulder and pelvis together in the same plane as the patient stands. It is considered a positive test if pain occurs within the first 30 degrees of rotation.
• Distracted straight leg raise discrepancy – The patient complains of pain during a straight leg raise during formal testing, such as when supine, but does not on distraction when the examiner extends the knee with the patient in a seated position.
• Regional sensory disturbance –The patient experiences decreased sensation fitting a stocking-like distribution rather than a dermatomal pattern.
• Regional weakness – Weakness, cogwheeling, or the giving way of many muscle groups that are not explained on a neuroanatomical basis.
• Overreaction – A disproportionate and exaggerated painful response to a stimulus that is not reproduced when the same provocation is given later. These responses can include verbalization, facial expression, muscle tension, or tremor.[trx],[rx]

Straight Leg Raising Test

• The straight leg raising test was described by JJ First in his doctoral thesis in 1881. He attributed the test to his teacher Charles Lasègue, hence called the Lasègue sign. He attributed the sign to be due to compression of the sciatic nerve by the hamstrings. In 1884, de Beurmann in a cadaveric study identified the stretching of the sciatic nerve by straight leg raising and attributed the pain to the stretching of the sciatic nerve.
• Done with the patient supine. Raise the affected side with the knee in extension. Positive if the patient complains of pain in the back of thigh radiating into the calf.
• True positive SLR is exacerbation or reproduction of pain radiating along the back of the thigh into the calf in the symptomatic side at 0-700 of limb elevation. It is a test of nerve root irritation. If a patient complains of pain in the back or gluteal region, then the test is a false positive.
• It is highly sensitive for lower lumbosacral root compressions (0.80-0.97) but low specificity (0.40). Hence a negative SLR is more important clinically than a positive SLR.

Verification Of SLR

• Verification of SLR done to differentiate between pain due to hamstring tightness and sciatica. Verification manoeuvre Do SLR. Flex the knee slightly when pain is produced, pain disappears the limb can be raised further. Pain persists if false positive.

Variants Of SLR Test

• Crossed SLR – Described by Fajersztan.  Raising of straightened contralateral limb produced symptoms on the symptomatic side. Has a high specificity of 0.90.
• Bragaard’s test– Described by Fajersztan. Do SLR. Lower the limb slightly when pain is produced, dorsiflex the ankle. Pain reproduced if positive.
• Bowstring test– Do SLR. Lower the limb slightly when pain is produced, Pain disappears. Press on the popliteal fossa. Pain reproduced if positive.
• Cross-over sign– Do SLR. pain radiates into the affected limb and the opposite limb. Indicates a midline lesion, severe enough to compress nerve roots on both sides.

Slump Test

• Position of patient – Seated upright.
• Position of examiner – Standing on the side of the patient
• Procedure – Ask the patient to slump first. If pain is not produced then ask the patient to bring his head onto the chest, extend his knee and dorsiflex his ankle one step at a time.
• Interpretation – Provocative sciatica is taken as a sign of neuromenigeal irritation.
• Use – Used as an alternative for the SLR test.

Quadrant Test

• Position of patient – Standing
• Position of examiner – Standing behind the patient
• Procedure – Keep one hand over the patient’s contralateral shoulder and apply axial pressure. Ask the patient to hyperextend, rotate and laterally flex to the contralateral side.
• Interpretation – Provocative pain is taken as a sign of lumbar instability.
• Use – Used if pain cannot be produced by forwarding flexion, lateral flexion etc.

Adams Forward Bending Test

• Position of patient – Standing with feet together, knee extended.
• Position of examiner – Standing behind the patient first then in front of the patient.
• Procedure – Rule out limb length discrepancy. Ask the patient to bend forwards at the waist till the back is in the horizontal plane. Palms should be held together.
• Interpretation – If there is a rib or loin hump present, then there is structural scoliosis with rotation.
• Use – To differentiate between structural and non-structural scoliosis.
• Validity of test –  For a patient with 40 structural scolioses, the test has a sensitivity of 0.83 and a specificity of 0.99.

Lab Test

• A medical history – in which you answer questions about your health, symptoms, and activity.
• A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
• Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
• Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
• Elevated CRP – levels are associated with infection.

Imaging

• X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, or fractures. It’s not possible to diagnose a herniated disc with this test alone.
• Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with a bulging disc. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression. It can also detect bony overgrowth, spinal cord tumors, or abscesses.
• A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, a bulging disc in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, spinal cord tumors, and abscesses. A CT scan may follow this test.
• Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc is damaged.
• Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc.
• Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure.

Treatment of Posterior Disc Bulge Between T12 – L1

Non-Surgical

• Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
• Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support
• Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.
• Hot Bath –  Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.
• Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
• Traction: May be beneficial in reducing the radicular symptoms associated with disc herniations. Traction is the best essential treatment for bulging discs, pinched nerves, radiating pain management. It can be done in a manual and dynamic way to relieves pain in bulging discs. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
• Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower back pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
• Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
• Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
• Back school –  is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
• Patient education – on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
• Physical therapy – which may include ultrasound, massage, conditioning, and exercise. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury. Physical therapists can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness.
• Over the Door Traction – This is a very effective treatment for a disc bulge. It helps in relieving muscle spasms and pain. Typically a 5 to 10-pound weight is used and it is important that patients do this under medical guidance.
• Weight control – By keto diet or maintaining or changing the food habit to reduce the weight not any movement during the time of acute pain.
• Use of a lumbosacral back support
• Typically – conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.
• Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal back pain of all types. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
  • In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

Medications

• Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen.
• Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
• Dietary supplement – to remove general weakness & improved health.
• Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Oral Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
• Steroid injections  The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves (Fig. 3). About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or home exercise program.
  • epidural steroid injection. A steroid solution is injected into the epidural space (outer layer of the spinal canal) to reduce inflammation. This injection is by far the most common one used for herniated discs.
  • Selective nerve root injection. A steroid solution and anesthetic is injected near the spinal nerve as it exits through the intervertebral foramen. This injection is also used to help diagnose which nerve root might be causing pain.

Surgery

• Microdiscectomy – for a herniated disc, a minimally invasive procedure in which the herniated portion of the disc is removed.
• Artificial disc replacement – for degenerative disc disease and herniated discs is a minimally invasive procedure that replaces a damaged disc with a specialized implant that mimics the normal function of the disc, maintaining mobility.
• Spinal fusion – fusion for degenerative disc disease, in which the disc space is fused together to remove motion at the spinal segment. Spinal fusion involves setting up a bone graft, as well as possible implanted instruments, to facilitate bone growth across the facet joints. Fusion occurs after the surgery.
• Open Back Surgery – Traditionally, bulging discs are treated with an open back procedure, meaning the surgeon makes a large incision into the skin and cuts muscle and surrounding tissue to gain access to the problematic disc. This traditional surgical option is invasive, requires overnight hospitalization, general anesthesia, and requires a lengthy recovery coupled with strong pain medication.
• Endoscopic Surgery – Fortunately, you have a second option with endoscopic spine surgery. Thanks to the advancement of surgical technology a bulged disc surgery can be performed using endoscopic procedures, meaning the surgeon makes a small incision to insert special surgical tools. During an endoscopic bulging disc operation, the surgeon uses a tiny camera to visualize and gain access to your damaged disc. This minimally invasive new approach offers shorter recovery, easier rehabilitation, and a much higher success rate than open back or neck surgery. A local anesthetic is all that is usually required.

Physiotherapy Treatment For Disc Bulging

Most minor and moderately bulging disc injuries are treated conservatively without the need for surgery. Torn fibers of the annulus will heal and the disc bulge usually resolves fully.

• While this occurs, your bulging disc treatment centers on encouraging the fluid to return and remain in the center of the disc. This rehabilitation keeps the torn fibers closer to one another and the structure of the annulus as healthy as possible.
• Your physiotherapist will advise you on the best positions to stay in and may tape or brace your spine. They’ll also explain to you the postures to avoid, which can be detrimental to your recovery.
• By maintain the disc fluid in the central position that you intend it to stay, you are helping Mother Nature to lay down its scar tissue optimally for an excellent long-term solution. Please remember that scar tissue formation will take at least six weeks, so the longer that you avoid aggravating postures, the better!

PHASE I – Pain Relief & Protection

• Managing your pain is usually the main reason that you seek treatment for a bulging disc. In truth, it was the final symptom that you developed and should be the first symptom to improve.
• You are managing your inflammation. Inflammation is the primary short-term reason why you have suddenly developed bulging disc symptoms. It best reduced via ice therapy and techniques or exercises that unload the inflamed structures.
• Your physiotherapist will use an array of treatment tools. They aim to reduce your pain and inflammation. These treatment modalities may include ice, electrotherapy, acupuncture, unloading taping techniques, soft tissue massage, gentle exercise, and temporary use of a back brace. Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen.

PHASE II – Bulging Disc Exercises

• As your pain and inflammation settle, your physiotherapist will turn their attention to restoring your normal joint alignment and range of motion, muscle length and resting tension, muscle strength, and endurance.
• Your physiotherapist will commence you on a lower abdominal and core stability program to facilitate your important muscles that dynamically control and stabilize your spine.
• Researchers have discovered the importance of your back and abdominal core muscle recruitment patterns. Standard recruitment order of your deeper muscles, then intermediate and finally, superficial muscle firing patterns are typically required to prevent back pain. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you, specific to your needs.
• Your physiotherapist may recommend a stretching program or a remedial massage to address your tight or shortened muscles. Please ask your physio for their advice.

PHASE III – Restoring Full Function

• As your back’s dynamic control improves, your physiotherapist will turn their attention to restoring your normal pelvic and spine alignment and its range of motion during more stressful body positions and postures. They’ll also work on your outer core and leg muscle power.
• Depending on your chosen work, sport or activities of daily living, your physiotherapist will aim to restore your function to allow you to return to your desired activities safely. Everyone has different demands for their body that will determine what specific treatment goals you need to achieve. For some, it is merely to walk around the block. Others may wish to run a marathon.

Your physiotherapist will tailor your back rehabilitation to help you achieve your own functional goals.

PHASE IV – Preventing a Recurrence

• Back pain does tend to return. The main reason back pain recurs is due to insufficient rehabilitation. In particular, poor compliance with deep abdominal and core muscle exercises. You should continue a version of these exercises routinely a few times per week. Your physiotherapist will assist you in identifying the best activities for you to continue indefinitely.
• In addition to your muscle control, your physiotherapist will assess your spine and pelvis biomechanics and correct any defects. It may be as simple as providing you with adjacent muscle exercises or some foot orthotics to address any biomechanical faults in the legs or feet.
• General exercise is a vital component to successfully preventing a recurrence. Your physiotherapist may recommend pilates, yoga, swimming, walking, hydrotherapy, or a gym program. These modalities all appear to help back pain. Exercise will assist your back pain relief in the long term.

Bulging Disc Exercises

You physiotherapist will prescribe the best bulging disc exercises. They will consider your disc bulge location, size, neurological symptoms and the acuteness of your symptoms. Please follow their recommendations as they guide you from back pain and back towards your healthy life.

Fine-tuning and maintenance of your back stability and function are best achieved by addressing any deficits and learning self-management techniques. Your physiotherapist will guide you.

What is Physiotherapy Treatment?

Physiotherapists help people affected by illness, injury, or disability through exercise, manual joint therapy, soft tissue techniques education, and advice.  Physiotherapists maintain physical health, help patients to manage pain, and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.

There is a multitude of different physiotherapy treatment approaches.

Acute & Sub-Acute Injury Management

• Early Acute Injury Treatment
• Sub-Acute Soft Tissue Injury Treatment

Hands-On Physiotherapy Techniques

Your physiotherapist’s training includes hands-on physiotherapy techniques such as:

• Joint Mobilisation (gentle joint gliding techniques)
• Joint Manipulation
• Physiotherapy Instrument Mobilisation (PIM)
• Minimal Energy Techniques (METs)
• Massage
• Soft Tissue Techniques

Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.

Physiotherapy Taping

Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.

• Supportive Strapping
• Kinesiology Taping

Alternatively, your physiotherapist may recommend a supportive brace.

Acupuncture and Dry Needling

Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.

• Acupuncture
• Dry Needling

Physiotherapy Exercises

Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the “best exercises” for you and the most appropriate “exercise dose” for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.

• Muscle Stretching
• Core Exercises
• Strengthening Exercises
• Neurodynamics
• Balance Exercises
• Proprioception Exercises
• Real-Time Ultrasound Physiotherapy
• Swiss Ball Exercises

Biomechanical Analysis

Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.

• Biomechanical Analysis
• Bike Fit Setup
• Gait Analysis
• Video Analysis

Hydrotherapy

Aquatic water exercises are an effective method to provide low bodyweight exercises.

• Hydrotherapy

Sports Physiotherapy

Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.

• Sports Injury Management
• Prehabilitation

Vestibular Physiotherapy

• BPPV Manoeuvres
• Vestibular Physiotherapy
• Falls Prevention

Women’s Health

Women’s Health Physiotherapy is a particular interest group of therapies.

• Women’s Health Physiotherapy
• Pelvic Floor Exercises

Workplace Physiotherapy

Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstations set up for your body at work or home. Whether it be lifting technique improvement, education programs, or workstation setups, your physiotherapist can help you.

• Home / Office Workstation Setup
• Corporate Wellness
• Workplace Wellness

Electrotherapy

• Electrotherapy & Local Modalities
• Therapeutic Ultrasound
• TENS Machines
• EMS Machines

Plus Much More

Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.

Exercises for low back pain

The following exercises can help ease pain in the lower back by building the muscles in the back. This will provide more support and help prevent future injuries.

4. Back flexion stretch

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Back flexion exercises stretch the spine and back muscles. Speak to a doctor before performing these exercises after a back injury. To perform a back flexion stretch:

• Lie on the back and hold both knees toward the chest.
• At the same time, move the head forward until there is a comfortable stretch across the mid and low back.
• Repeat this several times.

5. Knee to chest stretch

 

A knee to chest stretch will work the muscles on each side of the body separately for a gentler stretch. Try the following:

• Lie on the back with the knees bent and both heels on the floor.
• Place both hands behind one knee and pull it toward the chest.
• Switch legs and repeat several times.

6. Piriformis muscle stretch

The piriformis muscle is a small muscle located deep in the buttocks. To stretch this muscle:

• Lie on the back with the knees bent and both heels on the floor.
• Cross one leg over the other, resting the ankle on the bent knee.
• Gently pull the crossed knee toward the chest until there is a stretch in the buttock.
• Repeat on both sides.

References

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