Bulging or herniated lumbar disc? Which one is worse?
I get asked this question a lot. Which one is worse? Bulged or herniated disc?
With the invention of magnetic resonance imaging or MRI, the discs between the vertebral bones
could be visualized much better. This is how a normal intervertebral
disc looks like. An MRI takes a picture and shows tiny details about the disc. Over the past decades
we discovered that almost nobody has all 23 discs normal like this. Maybe in their first years of
life, but as soon as we start standing up and moving the spine, the discs start degenerating.
37% of children have disc degeneration, 30% have a disc bulge and 29% have a disc protrusion.
And these are children who do not complain of any back pain. They are asymptomatic.
Disc bulging is a very common finding in MRI. So should we be concerned about it? Should we treat
it? Does disc bulge progress to disc herniation, a more serious condition that usually cause pain?
So, let’s talk about disc bulges and disc herniations today.
I prepared a document that summarizes the main points of this video. Go to
the description below to download this summary. There are 23 discs in the spine, 6 in the neck,
12 in the thoracic spine and 5 in the lumbar spine.
The discs look like cushions to absorb pressure put on the spine. Any disc in the spine can
suffer degeneration, but the most common are the discs in the lumbar spine.
The discs have this central portion that is a gel-like cushion, it is called nucleus pulposus,
which is held together by these outer fibres called the annulus fibrosus. The anulus fibrosus
is made of several layers of fibrocartilage made up of type I and type II collagen.
Before I continue, let me remind you that this video is not intended to replace medical advice.
It is for educational purposes only. If you need medical advice, contact your doctor.
In case of emergency, go to the nearest emergency department or call 911.
A disc bulge is when the disc circumference is larger than the diameter of the vertebral bone.
We see here in this picture an MRI of the lumbar spine. these are the vertebral bones.
Lumbar 1, L2, L3, L4 and L5. We see the disc between L1 and L2 is normal, the nucleus pulposus
is inside the annulus, the disc between L2 and L3 is also good. The disc between L3 and L4 is
thinner, we hardly see the nucleus pulposus. This is disc desiccation. and we see that the diameter
of the disc is larger than the vertebra, that the disc is bulging. A normal disc is like a tire,
and the bulged disc is like a flat tire. Here too, between L4 and L5 we see another disc bulge.
A disc bulge is very common, even in people who do not have any back pain.
It affects 60% of adults, and 84% of older adults, men or women.
Now, disc herniation is when the nucleus pulposus gets out of the annulus. Like in this picture.
There are mainly 3 types of disc herniation: • Disc protrusion, the nucleus pulposus material
is still protected by the annulus fibrosus. • In disc extrusion, the annulus is damaged,
allowing the nucleus pulposus to herniate beyond the normal bounds of the disc.
• In disc sequestration, the herniated material breaks off from the body of the nucleus pulposus.
A disc herniation may compress the nerve root that is exiting from this narrow hole between the upper
and the lower vertebrae. And this nerve compression will cause pain, not in the nerve
itself, but in the area that is innervated by it, usually the buttock, thigh and leg.
A disc herniation is an acute event. It usually occurs abruptly, with a twist,
a bend of the trunk, or a trauma to the spine. A disc bulge is a chronic problem, related to wear
and tear of the annulus fibrosus, and it may cause pain in the lower back area, but not
radiating pain to the thighs or legs, unless if there is compression of a nerve root. Disc bulges
that are very large may cause the spinal canal to be narrow, which is the cause of spinal stenosis.
Disc herniation usually causes pain in one side, the side where there is nerve root compression.
A disc bulge is what we call degenerative disc disease, and it may involve disc dissection
too. If it is the cause of the pain, it will lead to low back pain in the middle line.
The pain gets worse when the person bends forward, and the pain gets better when the person
bends backwards. Disc degeneration is very
common in people who do not have any symptoms. So, it is not because we find them in an MRI that
they explain the pain. 80% of asymptomatic adults have disc degeneration, and 96% of older adults.
Sometimes the pain is coming from the muscles around the spine, and not the discs.
Disc protrusion is also commonly found in MRIs of asymptomatic individuals,
35% of adults and 43% of older adults will show disc protrusion in their MRIs.
So remember, it is not because the MRI showed one of these abnormalities that your pain is
caused by it. It could well be that it is just a coincidence. That is why the doctor
needs to take a good history and do a physical examination to confirm if the pain is coming
from one of these structures or not. If your doctor, or your rehabilitation therapist
tells you that you have one of these conditions, then there is treatment for them. Remember the
toolkit of all tools that we have to treat pain and restore function. The toolkit includes the
5M IS. The treatment for each of these conditions is different, but they all involve some kind of
exercise. I have other videos for these different conditons. I’ll put a link to these videos
in the description below. I have a video for degenerative disc disease, lumbar disc herniation,
spinal stenosis, facet joint syndrome and myofascial pain of the lumbar spine
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Thank you for watching. Goodbye!