Intervertebral Disc Herniation – Causes, Symptoms, Treatment

Disc herniation material  (i.e. herniated nucleus pulposus, HNP)

• Varying degrees of HNP is recognized, from disc protrusion (annulus remains intact), extrusion (annular compromise, but herniated material remains continuous with disc space), to sequestered (free) fragments
• HNP material predictably is resorbed over time, with the sequestered fragment demonstrating the highest degree of resorption potential
• In general, 90% of patients will have an asymptomatic improvement in radicular symptoms within 3 months following nonoperative protocols alone

Hypertrophy/expansion of degenerative tissues

• Common sources include ligamentum flavum and the facet joint.  The facet joint itself undergoes degenerative changes (just like any other joint in the body) and synovial hypertrophy and/or associated cysts can compromise surrounding nerve roots.

Degenerative conditions of the spine (most common causes)

• Spondylolisthesis – in the degenerative setting, this occurs as a result of a pathologic cascade including intervertebral disc degeneration, ensuing intersegmental instability, and facet joint arthropathy
• Spinal stenosis

• Adult isthmic spondylolisthesis – is typically caused by an acquired defect in the par interarticularis

  • Pars defects (i.e. spondylolysis) in adults are most often secondary to repetitive microtrauma.

• Clinicians should recognize spinal fractures can occur in younger, healthy patient populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary low energy injuries and spontaneous fractures in the elderly populations, including any patient with osteoporosis
• Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic exam.

• Benign or malignant tumors

  • Metastatic tumors (most common)
  • Primary tumors
  • Ependymoma
  • Schwannoma
  • Neurofibroma
  • Lymphoma
  • Lipomas
  • Paraganglioma
  • Ganglioneuroma
  • Osteoblastoma

Diagnosis of Intervertebral Disc Herniation

History

As part of the evaluation of neck pain, it is important to identify certain red flags that could be features of underlying inflammatory conditions, malignancy, or infection.[rx] These include:

• Fever, chills
• Night sweats
• Unexplained weight loss
• History of inflammatory arthritis, malignancy, systemic infection, tuberculosis, HIV, immunosuppression, or drug use
• Unrelenting pain
• Point tenderness over a vertebral body
• Cervical lymphadenopathy

Physical Examination

• The clinician should assess the patient’s range of motion (ROM), as this can indicate the severity of pain and degeneration. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Careful attention should also focus on any sign of spinal cord dysfunction.

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

• C2 Nerve – eye or ear pain, headache. History of rheumatoid arthritis or atlantoaxial instability
• C3, C4 Nerve – vague neck, and trapezial tenderness and muscle spasms
• C5 Nerve – neck, shoulder, and scapula pain. Lateral arm paresthesia. Primary motions affected include shoulder abduction and elbow flexion. May also observe weakness with shoulder flexion, external rotation, and forearm supination. Diminished biceps reflex.
• C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral forearm, lateral hand, and lateral two digits. Primary motions affected include elbow flexion and wrist extension. May also observe weakness with shoulder abduction, external rotation, and forearm supination and pronation — diminished brachioradialis reflex.
• C7 Nerve – neck and shoulder pain. Paresthesia of the posterior forearm and third digit. Primary motions affected include elbow extension and wrist flexion. Diminished triceps reflex
• C8 Nerve – neck and shoulder pain. Paresthesia of the medial forearm, medial hand, and medial two digits. Weakness during finger flexion, handgrip, and thumb extension.
• T1 Nerve – Neck and shoulder pain. Paresthesia of the medial forearm. A weakness of finger abduction and adduction.[rx][rx][rx]

Special Tests

• Lasègue’s Test
• Slump Test
• Muscle Weakness or Paresis
• Reflexes
• Hyperextension Test The patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pan deteriorates.
• Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling, or numbness.

Lab Values

• RBS
• Serum creatinine
• ESR and CRP – These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatic, seronegative spondyloarthropathy). These can also be beneficial if an infectious etiology is suspected.
• CBC with differential – Useful to obtain in instances when infection or malignancy is suspected.

Radiological Imaging

• X-rays – The first test typically performed and one that is very accessible at most clinics and outpatient offices. Three views (AP, lateral, and oblique) views help assess the overall alignment of the spine as well as for the presence of any degenerative or spondylotic changes. These can be further supplemented with lateral flexion and extension views to assess for the presence of instability. If imaging demonstrates an acute fracture, this requires additional investigation using a CT scan or MRI. If there is a concern for atlantoaxial instability, the open mouth (odontoid) view may assist in diagnosis.
• CT Scan – This imaging is the most sensitive test to examine the bony structures of the spine. It can also show calcified herniated discs or any insidious process that may result in bony loss or destruction. In patients that are unable to or are otherwise ineligible to undergo an MRI, CT myelography can be used as an alternative to visualize a herniated disc.
• MRI – The preferred imaging modality and the most sensitive study to visualize a herniated disc, as it has the most significant ability to demonstrate soft-tissue structures and the nerve as it exits the foramen.
• Electrodiagnostic testing – (Electromyography and nerve conduction studies) can be an option in patients that demonstrate equivocal symptoms or imaging findings as well as to rule out the presence of a peripheral mononeuropathy. The sensitivity of detecting cervical radiculopathy with electrodiagnostic testing ranges from 50% to 71%.[rx]
• The straight leg raise test – With the patient lying supine, the examiner slowly elevates the patient’s led at an increasing angle, while keeping the leg straight at the knee joint. The test is positive if it reproduces the patient’s typical pain and paresthesia.[rx]
• The contralateral (crossed) straight leg raise test – As in the straight leg raise test, the patient is lying supine, and the examiner elevates the asymptomatic leg. The test is positive if the maneuver reproduces the patient’s typical pain and paresthesia. The test has a specificity greater than 90%.
• Myelography – An X-ray of the spinal canal following the injection of contrast material into the surrounding cerebrospinal fluid spaces will reveal the displacement of the contrast material. It can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs.
• Transcranial Magnetic Stimulation (TMS) – The presence and severity of myelopathy can be evaluated by means of transcranial magnetic stimulation (TMS), a neurophysiological method that measures the time required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and ending at the anterior horn cells of the cervical, thoracic, or lumbar spinal cord. This measurement is called the central conduction time (CCT).
• Electromyography and nerve conduction studies (EMG/NCS) –  measure the electrical impulses along with nerve roots, peripheral nerves, and muscle tissue. Tests can indicate if there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or if there is another site of nerve compression. EMG/NCS studies are typically used to pinpoint the sources of nerve dysfunction distal to the spine.
• Other Studies – Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by the injured cervical disc.[rx][rx]

Treatment Of Intervertebral Disc Herniation

Patient Education

• Use of hot or cold packs for comfort and to decreased inflammation
• Avoidance of inciting activities or prolonged sitting/standing
• Practicing good, erect posture
• Engaging in exercises to increase core strength
• Gentle stretching of the lumbar spine and hamstrings
• Regular light exercises such as walking, swimming, or aromatherapy
• Use of proper lifting techniques

Non-Pharmacological Treatment

Conservative Treatments – Acute cervical or lumber radiculopathies secondary to a herniated disc are typically managed with non-surgical treatments as the majority of patients (75 to 90%) will improve. Modalities that can be used include[rx][rx][rx]:

• Rest the area by avoiding any activity that causes worsening symptoms in the arms or legs.
• Stay active around the house, and go on short walks several times per day. The movement will decrease pain and stiffness and help you feel better.
• Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
• Sit in firm chairs. Soft couches and easy chairs may make your problems worse.
• Deep tissue massage may be helpful
• Acupuncture – In acupuncture, the therapist inserts fine needles into certain points on the body with the aim of relieving pain.
• Reiki – Reiki is a Japanese treatment that aims to relieve pain by using specific hand placements.
• Moxibustion – This method is used heat specific parts of the body (called “therapy points”) by using glowing sticks made of mugwort (“Moxa”) or heated needles that are put close to the therapy points.
• Massages – Various massage techniques are used to relax muscles and ease tension.
• Heating and cooling – This includes the use of hot packs and plasters, a hot bath, going to the sauna, or using an infrared lamp. Heat can also help relax tense muscles. Cold packs, like cold wraps or gel packs, are also used to help with irritated nerves.
• Ultrasound therapy – Here the lower back is treated with sound waves. The small vibrations that are produced generate heat to relax body tissue.
• Cervical Manipulation – There is limited evidence suggesting that cervical manipulation may provide short-term benefits for neck pain and cervicogenic headaches. 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.
• Lumbar Corset or Collar for 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. 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.

Physical Therapy

• Exercising in water – can be a great way to stay physically active when other forms of exercise are painful. Exercises that involve lots of twisting and bending may or may not benefit you. Your physical therapist will design an individualized exercise program to meet your specific needs.
• Weight-training exercises – though very important, need to be done with proper form to avoid stress to the back and neck.
• Reduce pain and other symptoms – Your physical therapist will help you understand how to avoid or modify the activities that caused the injury, so healing can begin. Your physical therapist may use different types of treatments and technologies to control and reduce your pain and symptoms.
• Improve posture –If your physical therapist finds that poor posture has contributed to your herniated disc, the therapist will teach you how to improve your posture so that pressure is reduced in the injured area, and healing can begin and progress as rapidly as possible.
• Improve motion – Your physical therapist will choose specific activities and treatments to help restore normal movement in any stiff joints. These might begin with “passive” motions that the physical therapist performs for you to move your spine, and progress to “active” exercises and stretches that you do yourself. You can perform these motions at home and in your workplace to help hasten healing and pain relief.
• Improve flexibility – Your physical therapist will determine if any of the involved muscles are tight, start helping you to stretch them, and teach you how to stretch them at home.
• Improve strength – If your physical therapist finds any weak or injured muscles, your physical therapist will choose, and teach you, the correct exercises to steadily restore your strength and agility. For neck and back disc herniations, “core strengthening” is commonly used to restore the strength and coordination of muscles around your back, hips, abdomen, and pelvis.
• Improve endurance – Restoring muscular endurance is important after an injury. Your physical therapist will develop a program of activities to help you regain the endurance you had before the injury, and improve it.
• Learn a home program – Your physical therapist will teach you strengthening, stretching, and pain-reduction exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.

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 broken bones 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 repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
• Broken bones need 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.

Medication

Pharmacotherapy – There is no evidence to demonstrate the efficacy of non-steroidal anti-inflammatories (NSAIDs) in the treatment of cervical radiculopathy. However, they are commonly used and can be beneficial for some patients. The use of COX-1 versus COX-2 inhibitors does not alter the analgesic effect, but there may be decreased gastrointestinal toxicity with the use of COX-2 inhibitors. Clinicians can consider steroidal anti-inflammatories (typically in the form of prednisone) in severe acute pain for a short period. A typical regimen is prednisone 60 to 80 mg/day for five days, which can then be slowly tapered off over the following 5 m to 14 days. Another regimen involves a prepackaged tapered dose of Methylprednisolone that tapers from 24 mg to 0 mg over 7 days.

• Non-steroidal anti-inflammatory drugs (NSAIDs) – These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen, and naproxen. Anti-inflammatory drugs are drugs that reduce inflammation. This includes substances produced by the body itself like cortisone. It also includes artificial substances like ASA – acetylsalicylic acid (or “aspirin”) or ibuprofen –, which relieve pain and reduce fever as well as reducing inflammation.
• Acetaminophen (paracetamol) – Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.
• Opioids – Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation. Taking these drugs for a long time can lead to habitual use and physical dependence.
• Skeletal Muscle relaxant – If muscle spasms are prominent, the addition of a muscle relaxant may merit consideration for a short period. For example, cyclobenzaprine is an option at a dose of 5 mg taken orally three times daily. Antidepressants (amitriptyline) and anticonvulsants (gabapentin and pregabalin) have been used to treat neuropathic pain, and they can provide a moderate analgesic effect.
• Steroids – Anti-inflammatory drugs that can be used to treat various diseases systemically. That means that they are taken as tablets or injected. The drug spreads throughout the entire body to soothe inflammation and relieve pain. Steroids may increase the risk of gastric ulcers, osteoporosis, infections, skin problems, glaucoma, and glucose metabolism disorders.
• Muscle relaxants – Sedatives which also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect liver functions and cause gastro-intestinal complications. Drugs from the benzodiazepine group, such as tetrazepam, can lead to dependency if they are taken for longer than two weeks.
• Nerve Relaxant and Neuropathic Agents – Drugs(pregabalin & gabapentin) or Vitamin B1 B6, B12 and mecobalamin that address neuropathic—or nerve-related pain remover. This includes burning, numbness, and tingling.
• Anticonvulsants – These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
• Antidepressants – These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat, and fatigue.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• 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 tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Injections near the spine – Injection therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:
  • In lumbar spinal nerve analgesia (LSPA) – the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root.
  • In lumbar epidural analgesia – the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or X-rays to make sure that the injection is placed at exactly the right spot.
  • Interventional Treatments – Spinal steroid injections are a common alternative to surgery. Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[15]

Surgical Treatments

• Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF) – Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, a curette, and a burr drill to remove affected disc. The posterior longitudinal ligament can be left in situ depending on the severity of the herniation.
• Laminectomy – Cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression. Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.
• Laminoplasty – The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina. Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.[rx]
• Anterior cervical discectomy and fusion – A procedure that reaches the cervical spine (neck) through a small incision in the front of the neck. The intervertebral disc is removed and replaced with a small plug of bone or another graft substitute, and in time, that will fuse the vertebrae.
• Cervical corpectomy – A procedure that removes a portion of the vertebra and adjacent intervertebral discs to allow for decompression of the cervical spinal cord and spinal nerves. A bone graft, and in some cases a metal plate and screws, are used to stabilize the spine.
• Dynamic Stabilisation – Following a discectomy, a stabilization implant is implanted with a ‘dynamic’ component. This can be with the use of Pedicle screws (such as Dynesys or a flexible rod) or an interspinous spacer with bands (such as a Wallis ligament). These devices offload pressure from the disc by rerouting pressure through the posterior part of the spinal column. Like a fusion, these implants allow maintaining mobility to the segment by allowing flexion and extension.
• Facetectomy – A procedure that removes a part of the facet to increase the space.
• Foraminotomy – A procedure that enlarges the vertebral foramen to increase the size of the nerve pathway. This surgery can be done alone or with a laminotomy.
• Intervertebral disc annuloplasty (IDET) – A procedure wherein the disc is heated to 90 °C for 15 minutes in an effort to seal the disc and perhaps deaden nerves irritated by the degeneration.
• Intervertebral disc arthroplasty – also called Artificial Disc Replacement (ADR), or Total Disc Replacement (TDR), is a type of arthroplasty. It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial ones in the lumbar (lower) or cervical (upper) spine.
• Laminoplasty – A procedure that reaches the cervical spine from the back of the neck. The spinal canal is then reconstructed to make more room for the spinal cord.
• Laminotomy – A procedure that removes only a small portion of the lamina to relieve pressure on the nerve roots.
• Microdiscectomy – A minimally invasive surgical procedure in which a portion of a herniated nucleus pulposus is removed by way of a surgical instrument or laser while using an operating microscope or loupe for magnification.
• Percutaneous disc decompression – A procedure that reduces or eliminates a small portion of the bulging disc through a needle inserted into the disc, minimally invasive.
• Spinal decompression – A non-invasive procedure that temporarily (a few hours) enlarges the intervertebral foramen (IVF) by aiding in the rehydration of the spinal discs.
• Spinal laminectomy – A procedure for treating spinal stenosis by relieving pressure on the spinal cord. A part of the lamina is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.

Complications of Intervertebral Disc Herniation

Complications from steroid injections are typically mild and range between 3% to 35% of cases. Other, more serious complications can include[rx]

• Nerve injury
• Infection
• Epidural hematoma
• Epidural abscess
• Spinal cord infarction
• Bleeding
• Recurrence of disease or symptoms
• Infection
• Worsening neurological deficits
• Failed operation

Complications from surgical intervention include[rx]

• Infection
• Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
• Esophageal injury
• Vertebral and carotid injuries
• Dysphagia
• Horner syndrome
• Pseudoarthrosis
• Adjacent segment degeneration

 A team approach is an ideal way to limit the complications of such an injury

• Evaluation of a patient with lumbar radicular pain by the primary care provider to rule out severe radiculopathy or alarm symptoms is the recommended first step.
• Conservative management should commence when symptoms are mild or moderate; including moderate activity, stretches, and pharmacological management. A pharmacist should evaluate dosing and perform medication reconciliation to preclude any drug-drug interactions, and alert the healthcare team regarding any concerns.
• The patient should follow up with primary care physicians one to two weeks following initial injury to monitor for progression of the nerve damage.
• If symptoms worsen on follow up or there is a concern for the development of a severe radiculopathy referral to neurosurgery or hospitalization for possible spinal decompression.
• If radicular symptoms persist three weeks after injury, physical therapy referral can be a consideration.
• When symptoms persist for greater than six-week duration, imaging such as MRI or CT can are options for better visualization of the nerve roots.
• The patient should consult with a dietitian and eat a healthy diet and maintain a healthy weight.
• The pharmacist should encourage the patient to quit smoking, as this may help with the healing process. Further, the pharmacist should educate the patient on pain management and available options.
• Persistent pain at six weeks follows up may warrant a referral to interventional pain management or neurosurgery for an epidural steroid injection.
• If mild to moderate symptoms continue at three months following the onset of symptoms, referral for possible surgical intervention merits consideration as well.

Prevention

To prevent experiencing a herniated disc, individuals should:

• Use proper body mechanics when lifting, pushing, pulling, or performing any action that puts extra stress on your spine.
• Maintain a healthy weight. This will reduce the stress on your spine.
• Stop smoking.
• Discuss your occupation with a physical therapist, who can provide an analysis of your job tasks and offer suggestions for reducing your risk of injury.
• Keep your muscles strong and flexible. Participate in a consistent program of physical activity to maintain a healthy fitness level.

Many physical therapy clinics offer “back schools,” which teach people how to take care of their backs and necks and prevent injury. Ask your physical therapist about programs in your area. If you don’t have a physical therapist.

To prevent recurrence of a herniated disc, follow the above advice, and:

• Continue the new posture and movement habits that you learned from your physical therapist, to keep your back healthy.
• Continue to do the home-exercise program your physical therapist taught you, to help maintain your improvements.
• Continue to be physically active and stay fit.

You Can Prevent Lumbar Disc Herniation By Exercise Regular With This Machine

References