Protrusion of discs of the lumbar spine: symptoms, treatment and surgery

28 February 2020

105536

3.8 out of 5

The intervertebral disc of the lumbar region is a fibrocartilaginous formation, the shape of which is close to an oval. It is formed by an elastic nucleus pulposus and a strong fibrous membrane and acts as a shock absorber between the vertebral bodies.

The intervertebral discs of the lumbar spine are the largest and most often susceptible to degenerative changes due to the highest level of mobility and the load received.

What is lumbar disc protrusion?

The lumbar spine is formed by 5, sometimes 6 vertebrae. Between them are intervertebral discs, which are designated depending on which vertebral bodies they are located between: L1–L2, L2–L3, L3–L4, L4–L5. Their nutrition is carried out through the circulatory system of the vertebrae and diffusely through the upper and lower surfaces of the disc (endplates).

They are natural gaskets between the bone elements of the spine and ensure the preservation of their integrity, stability of position, as well as mobility and flexibility of the ridge.

Protrusions of the lumbar spine account for about 90% of all cases of their formation. They most often occur in the L5–S1 and L4–L5 discs.

Age-related changes, the negative effects of external factors, a sedentary lifestyle and a number of other reasons lead to disruption of blood circulation and disk nutrition. The consequence is degenerative-dystrophic processes in the disc, i.e. osteochondrosis develops.

If left untreated, degenerative changes progress, spreading to the marginal plates and causing them to become sclerotic. This prevents the flow of nutrients into the nucleus pulposus, which provokes a decrease in the moisture content in it and the occurrence of nutritional deficiency. This subsequently leads to the formation of protrusion. In such situations, the disc is already so damaged that its shape is deformed, the fibrous ring becomes thinner and a slight protrusion forms.

After all, a lack of water and nutrients leads to the separation of collagen fibers, from which the fibrous ring is formed, as well as their microtears. This creates the preconditions for the nucleus pulposus to move towards the area of thinning, which puts increased pressure on the already deformed annulus fibrosus. Gradually, it ceases to cope with the increased load, an even greater number of collagen fibers are torn, which leads to the bulging of the disc into the spinal canal.

As long as the integrity of the fibrous ring is preserved, they speak of the presence of protrusion. But in the absence of therapy, the pressure of the nucleus pulposus on the fibrous membrane does not disappear, so more and more collagen fibers are destroyed. As a result, the fibrous ring ruptures, and the internal contents of the disc are able to come out into the spinal canal. This is how a hernia is formed.

Thus, protrusion is a manifestation of osteochondrosis, manifested by the formation of a slight protrusion of the intervertebral disc beyond the physiological boundaries, but while maintaining the integrity of the fibrous ring.

Today, osteochondrosis occurs in people of all ages and is extremely rarely diagnosed in the early stages. Usually the disease is detected when it has already led to protrusion, since even minor changes in the condition of the lumbar intervertebral discs lead to pain and other disorders.

Causes of protrusion

A herniated disc occurs as a result of wear and tear on the intervertebral disc, most often as a result of gradual age-related wear. As we age, the inner gel-like substance of the spinal discs begins to lose flexibility, causing the discs to more easily slip out of place and put pressure on surrounding nerves. An important factor in accelerated disc degeneration is a person's lifestyle and daily habits. Some people do a lot of heavy work using incorrect movements, which causes the discs to support too much weight. For those who play sports, a herniated disc can be the result of repetitive movements and a forceful impact on the discs or a sudden twisting movement. People who are overweight are also at increased risk of herniated discs due to the extra weight the discs must support. All of these can accelerate disc degeneration or cause a disc to rupture, putting pressure on surrounding nerves.

Stages and types

Depending on the severity of the situation, there are 3 stages of development of lumbar protrusion:

Mild - the protrusion is barely noticeable, so even with the use of modern high-precision examination methods, not every specialist will be able to notice it. The dimensions of the protrusion do not exceed 1 mm.
Moderate – the protrusion increases and already reaches 1–3 mm.
Severe – the formation of a bulging intervertebral disc is no longer in doubt. It is clearly visualized beyond the boundaries of the vertebral bodies and has dimensions from 3 to 6 mm. But the annulus fibrosus still maintains its integrity.

The third stage of development of protrusion borders on extrusion, i.e. the formation of a hernia. Therefore, when such a protrusion is detected, the fibrous ring, thinned to the limit, may not withstand the load at any moment and burst. As a result, the nucleus pulposus gradually comes out, i.e., an intervertebral hernia is formed.

But the size of the protrusion is not the only sign by which pathology is classified. Its position relative to the central axis of the spinal canal is of great importance for determining treatment tactics. Therefore, protrusions are distinguished:

dorsal – the protrusion is directed posteriorly;
lateral – formed on the right or left side of the spine;
foraminal - the bulge “leaks” into the foraminal openings of the spine, through which the nerve plexuses pass;
median - the protrusion is localized clearly in the center of the spinal canal, where there is a large nerve plexus, the so-called cauda equina;
circular - the fibrous ring becomes thinner over the entire surface area and more or less evenly protrudes into the spinal canal along its entire width.

Preventive measures and possible complications

If you ignore the problem and do not want to contact a specialist, the pathology can become progressive. This is fraught with the appearance of acute pain, compression of the spinal roots, rupture of the fibrous ring and the formation of a disc herniation. Moreover, prolonged compression of nerve endings can lead to paralysis in the legs and malfunction of the pelvic organs. Such negative manifestations can only be eliminated through surgical intervention. During the rehabilitation period, it is necessary to minimize the load on the spine, avoid prolonged stay in an uncomfortable position, lose weight, take daily walks in the fresh air, practice physical exercise and maintain a healthy lifestyle.

Causes

The main cause of the development of protrusion of intervertebral discs is osteochondrosis. The development of the disease is promoted by:

maintaining a sedentary lifestyle, sedentary work (office employees, drivers, etc.);
excessive stress on the spine caused by heavy physical work or playing certain sports;
metabolic disorders;
genetic predisposition;
poor development of the muscle corset that supports the spine;
curvature of the ridge (scoliotic deformity, kyphosis, lordosis);
back injuries;
excess weight;
unbalanced diet;
age-related changes.

Can I do exercises?

It’s not just possible to train with protrusion, but necessary! This is one of the effective methods of relaxing muscles, relieving inflammation and pain.

The main goal of physical therapy is to correctly distribute the load on the muscles and prevent the nerve root from being pinched, and for this you need to exercise regularly.

The main thing is to seek help from a specialist in time, who will prescribe the correct treatment and draw up an individual training program.

Symptoms

The main manifestation of pathological changes in the intervertebral discs is pain. Pain even at the early, so-called pre-hernia stage can be quite severe and protracted. They are often poorly controlled with painkillers. In this case, the biomechanics of the lumbar spine often deteriorates significantly.

The thing is that all people have different disc sizes, and the spinal roots pass at different distances from them. Therefore, in some patients, the pathology does not make itself felt for quite a long time, until the protrusion reaches enormous sizes, while in others, neurological symptoms and pain occur almost immediately and are acute.

Therefore, the size of the hernia or protrusion does not play a significant role in the need for surgery. Neurosurgeons are primarily guided by the patient’s condition, and therefore, in some cases, surgical intervention is indicated for protrusions and the presence of a congenitally narrow spinal canal.

In most cases, pain appears when the protrusion reaches stage 3 of development and its size exceeds 3 mm.

The occurrence of pain, especially acute pain, is a clear sign of compression of the spinal nerves. Often the pain is aching and dull, but it can also be burning or have the appearance of a lumbago. They can radiate to one or both legs, most often to the thigh and lower leg.

Lower back pain occurs when:

changing body position;
physical activity;
staying in one static position for a long time.

Also, protrusion of the lumbar spine can cause:

reduction in the possible range of motion in the lower back (most often it is difficult for patients to bend over and turn the body due to sudden or intensifying pain);
disturbances of sensitivity (parasthesia), which is manifested by the appearance of tingling, numbness or a feeling of crawling on the skin in the lumbar region, perineum or legs;
decreased muscle tone in the legs and reflex spasms of the back muscles in the projection of the affected area of the spine;
dysfunction of the pelvic organs occurs with a congenitally narrow spinal canal and compression of the nerves of the cauda equina, since they are responsible for control of urination, defecation, and the functioning of the genital organs;
rapid fatigue, decreased performance.

The severity of pain and neurological symptoms is determined by the location of the protrusion, its size, the degree of inflammation and the amount of nerve compression.

Such symptoms are often a reason for detailed consideration of the need for surgical intervention. Prolonged delay can provoke irreversible changes and lead to paralysis.

Contraindications

Please note that in some cases, gymnastics for protrusion of the lumbar spine can provoke the opposite effect and cause harm to the body. Contraindications to performing the exercises are as follows:

elevated body temperature (more than 37);
feverish condition;
mental disorders;
infectious diseases;
high blood pressure.

Diagnostics

At the first visit to the doctor, the patient is examined, during which his neurological status is assessed. A qualified specialist may immediately suspect the presence of protrusion, although not make an accurate diagnosis. Since a fairly large number of spinal diseases are accompanied by the development of neurological symptoms, it is possible to accurately determine the cause of its occurrence only through instrumental diagnostics.

Therefore, the patient is referred to:

X-ray;
MRI;
CT.

A thorough medical history must be taken and neurological tests performed. This allows you to evaluate:

the nature, strength and time of occurrence, as well as the frequency of pain attacks;
muscle strength, quality of coordination of movements and find a connection between episodes of increased pain and certain movements;
the level of physical activity of the patient before the onset of the disease and at the present time;
posture and determine the possible range of movement in different directions;
quality of reflexes and tactile sensitivity;
the condition of the vertebrae, the size of the intervertebral space and identify their displacement or the formation of osteophytes.

MRI provides the most complete information about the condition of intervertebral discs. Using this research method, it is possible to detect the smallest protrusions, even if their size does not reach 2 mm.

Sometimes patients are additionally prescribed radiography with functional tests. This test is designed to determine the presence of instability in the spine. This is an important diagnostic parameter when detecting vertebral displacement, which is often observed in people of any age and creates significant preconditions for the occurrence of compression radicular syndromes and a number of other spinal diseases.

Clinical manifestations of protrusion

In addition to back pain, additional symptoms may also occur:

1. Pain that radiates down one or both legs. 2. Weakness of the leg muscles, which does not allow the patient to walk normally. 3. Numbness of one or both legs. 4. Difficulty walking even short distances.

Of course, all these problems inevitably greatly interfere with normal life and activities. Pain from a herniated disc usually worsens when a person is active and decreases when they rest. Coughing, sneezing, sitting, driving, and bending forward can increase pain. The pain increases because these movements put more pressure on the nerve. People with a painful bulging disc often try to change positions to relieve pain.

Treatment of protrusion of the lumbar spine

Initially, for protrusions of lumbar intervertebral discs, conservative therapy is prescribed. In some cases, it helps to effectively combat exacerbations of the disease and is designed to:

eliminate pain and inflammation, which has a beneficial effect on the condition of the spinal roots;
improve the quality of blood circulation, which has a positive effect on metabolic processes and trophism of intervertebral discs;
stop the progression of destruction of the fibrous ring and prevent the transition of the protrusion into a hernia;
normalize the mobility of the pathologically altered segment of the spine;
prevent weakening of the back and leg muscles.

However, conservative therapy does not always completely stop degenerative processes. Therefore, very often, despite all efforts, protrusion of the lumbar intervertebral disc can still transform into a hernia over time.

Conservative therapy can lead to complete recovery and normalization of the structure and shape of the lumbar intervertebral disc, especially if it was started at the 1st stage of protrusion formation, when its size does not exceed 2 mm.

In order for conservative treatment to be effective and achieve the maximum objectives, it must be comprehensive and fully take into account all the features of the course of the disease, age, gender, the nature of the patient’s work activity and many other factors. Therefore, only a highly qualified vertebrologist can select the optimal treatment tactics.

As a rule, patients with diagnosed protrusions of the lumbar spine are prescribed:

drug therapy;
physiotherapy;
exercise therapy;
manual therapy;
diet and gentle regimen.

Methods of physiotherapy, exercise therapy and manual therapy can only be used outside the acute period of the disease.

Drug therapy

The effectiveness of the treatment largely depends on the correct selection of medications. Depending on the condition of the intervertebral discs, patients are prescribed:

NSAIDs – eliminate pain and inflammation, are used in the form of oral preparations, injections, ointments, creams or gels;
corticosteroids – have a pronounced anti-inflammatory effect and are used in acute, serious inflammatory processes;
chondroprotectors - designed to improve the quality of regeneration of cartilage tissue, improve the flow of metabolic processes in it;
B vitamins – normalize nerve conduction;
calcium supplements – increase bone density.

For each patient, the list of medications is selected individually. All medications must be taken in courses, sometimes very long, without allowing unnecessary breaks.

Physiotherapy

Physiotherapeutic procedures help improve the patient’s well-being and inhibit the progression of pathological changes in the tissues of the intervertebral disc. All procedures and their combinations are selected individually and prescribed in courses of 10–15 sessions.

The most effective treatment for protrusions of the intervertebral discs of the lumbar spine are:

traction therapy – involves traction of the spine using a special device, which helps to increase the intervertebral spaces and eliminate increased pressure on the discs;
electrophoresis – ensures effective delivery of drugs directly to the lesion, which gives a pronounced analgesic and anti-inflammatory effect;
shock wave treatment – used in the presence of spinal deformities, helps reduce pressure on nerve fibers and increase muscle tone;
laser therapy – stimulates metabolic processes, which ensures more active saturation of disc tissue with oxygen and nutrients, helps strengthen the immune system and reduce the severity of pain;
Magnetic therapy – aimed at improving the functioning of the circulatory system, which ensures increased nutrition of the intervertebral discs and strengthens the body’s own defenses;
relaxation at balneological resorts - has a positive effect on the entire body and psycho-emotional state, and is used as a preventive measure.

The most effective use of physical methods of influencing the body for protrusions of mild and moderate severity in the absence of pronounced neurological symptoms.

Exercise therapy

Therapeutic exercise is one of the most important components of conservative therapy. For each patient, an individual training program is drawn up by a specialist, taking into account his condition, level of physical fitness and the presence of other diseases.

Exercise therapy involves daily performance of a specially designed set of exercises that help:

reduce the load on the pathologically changed area;
increase muscle flexibility and strength;
have a tonic effect on the body;
activate blood circulation in the problem area and improve the course of metabolic processes;
normalize the size of the intervertebral space and create the prerequisites for the release of nerve roots.

The effectiveness of physical therapy has been clinically proven. The method allows you to keep lumbar protrusion under control and prevent its progression. But for this, the set of exercises and load must be selected strictly individually by a specialist. Otherwise, if you choose exercises without permission, the exercises will not bring good results or may even lead to a worsening of the patient’s condition.

All exercises are performed slowly, without sudden movements. The load is increased gradually and only with the permission of the attending physician.

The first exercise therapy sessions should be carried out under the supervision of a specialist. If pain occurs while performing any exercise, you should immediately stop the activity and consult a doctor to find out the causes of the pain syndrome and correct the physical therapy program.

Manual therapy

Manual therapy and therapeutic massage are aimed at restoring the normal anatomy of the spine, improving lymphatic drainage, blood circulation and activating metabolic processes. The use of manual therapy techniques restores muscle tone, improves the quality of reflexes and normalizes tactile sensitivity by reducing pathological pressure on the nerve roots. But for certain types of protrusions, massage is completely contraindicated.

Diet and gentle regimen

When diagnosing protrusion of the intervertebral disc of the lumbar spine, much attention is paid to the characteristics of the patient’s physical activity. It is important not only to avoid excessive stress on the lower back, but also low mobility. Therefore, patients are advised to give up heavy physical labor, especially those associated with lifting weights, and also regularly take walks, not forgetting about exercise therapy.

The effectiveness of conservative treatment also largely depends on the quality of nutrition. After all, it is with food that a person receives the bulk of the substances necessary for the proper functioning of biochemical transformations in the body.

Therefore, it is worth enriching your diet with foods that are sources of calcium:

fish;
fermented milk products;
veal;
poultry meat;
vegetables;
herbs (parsley, dill, basil are especially useful);
nuts.

It is also worth including dishes containing natural gelatin in the menu. These are meat broths, seaweed, marmalade, etc. It is important to limit the consumption of alcohol, fried, fatty and spicy foods.

If you are overweight, it is recommended to take measures to reduce it, since this leads to an increase in the load on the spine and negatively affects the condition of other organs.

It is recommended to eat 5-6 times a day in small portions. This will allow you to achieve the optimal combination of products, receive all the substances necessary for the proper functioning of the body and not overeat, which will have a positive effect on your weight and overall well-being.

The most effective exercises for protrusions

Exercises for thoracic protrusion of the spine should be performed based on the following general rules:

You should not overexert yourself, as this will negatively affect the condition of the discs and vertebrae, which are in the stage of degeneration.
Work out on an orthopedic mattress or gymnastics mat.
Take a three-minute rest after each exercise.
The first week, do the minimum number of repetitions.
Start taking a course of physical therapy only after your back pain goes away.
Do not drink liquid during exercise.

Thus, a course of therapeutic exercises will be as useful as possible and will help you quickly eliminate the pathology.

A selection of exercises for thoracic protrusion

Let's look at the eight most common exercises to eliminate pathology:

1. Take a standing position, keep your posture straight, do not bend your knees (there should be no distance between your feet). Tighten your legs, place your arms at your sides. Inhale deeply and at the same time raise your arms to your shoulders. Next, exhale and return to the starting position. Do three reps.

2. Stand up straight, place your palms on your back so that your fingers are along the spine. As you inhale, begin to press your palms on the vertebrae, smoothly lowering your arms down. Try to perform the exercise with the edges of your palms. Repeat the action five times.

3. Take a vertical position, place your palms on your shoulders. As you inhale, press down on your shoulders, and as you exhale, return to the starting position. Do five reps.

4. Take a standing position, clasp your hands behind your back into fists. Start pressing down on the vertebrae, pointing your hands down as if you were stretching the spine. Do three reps.

5. Stand up straight, clasp your hands behind your back. Inhale and at the same time pull your right hand back, and with your left begin to apply pressure to the vertebrae. Repeat the exercise three times on each hand.

6. Take a horizontal position. To perform this exercise, you will need a partner, who needs to press his palms on the ribs on both sides of the spine, moving from top to bottom. Please note that you should not feel any pain for 4 minutes.

7. Take a horizontal position and place a cushion under your spine. Close your hands at the back of your head. Bend the upper body, gradually lowering the roller so that it passes over the entire thoracic region.

8. Wrap a towel around your lower chest and take a deep breath. As you exhale, pull the edges of the towel as hard as possible. Perform ten repetitions.

These exercises are relevant at home.

Exercises in the gym

You can perform exercises for protrusion of the thoracic and cervical spine in the gym if you do it carefully and under the supervision of a specialist.

Safe exercises are:

wide grip pull-ups;
bending over the goat;
pulling the horizontal block with a narrow grip and the upper one with a wide grip;
bench press in a lying position with a wide grip;
dips;
incline bench press;
lifting dumbbells on a bench in a lying position.

It is recommended not to visit the gym on your own; discuss your training program with your doctor.

The effectiveness of yoga for protrusions

With a gentle effect on the spine, yoga really becomes an indispensable assistant in the treatment of protrusions.

With the help of a properly selected training program, you can strengthen tendons, muscles, ligaments, and make your spine more flexible.

Thanks to yoga, you will quickly get rid of pain and inflammation, restore blood flow, improve the immune system, and increase stress resistance.

You can engage in this sport at any age, the main thing is to choose the right treatment package in accordance with your health condition.

Surgery

In approximately 5–10% of patients with lumbar protrusions, surgical intervention is indicated. It is recommended for:

no positive changes in the patient’s condition after 3–6 weeks;
frequent attacks of severe pain;
disruption of the functioning of the nerves of the cauda equina;
chronic reflex and radicular syndrome;
rapidly increasing deterioration of the condition.
Congenitally narrow spinal canal

Today, preference is given to minimally invasive methods of percutaneous surgery (puncture nucleoplasty), which allows one to achieve excellent results with minimal trauma to soft tissues. The procedure is aimed at reducing the pressure inside the altered intervertebral disc of the lumbar spine, which creates the preconditions for restoring its normal shape and boundaries. This is achieved by influencing the nucleus pulposus:

cold plasma;
laser;
radio wave electromagnetic radiation;
hydroplastics

All methods work on approximately the same principle. The essence of puncture hydroplasty is the introduction, under the control of an image intensifier, into the pathologically altered disk of the nucleus pulposus from a posterior approach. The skin is pre-treated with an antiseptic solution.

Once the needle reaches the center of the nucleus, a working port is inserted into it, through which the nucleotome is inserted. Observing his actions through the monitor, the neurosurgeon turns on the device generator and begins to perform reciprocating movements in different planes, without going beyond the nucleus pulposus of the disc.

This leads to the removal of nuclear tissue at the site of passage of the nucleotome, which reduces its size, eliminates pathological pressure on the fibrous ring and promotes retraction of the protrusion.

The operation is performed under local anesthesia and does not require a hospital stay. It is performed on an empty stomach and takes on average no more than half an hour. After nucleoplasty, a puncture of no more than 2–5 mm in size remains on the skin, so it does not require sutures and heals independently, without leaving noticeable marks on the skin. The wound is covered with a sterile bandage.

The use of nucleoplasty is not recommended for patients over 50–55 years of age, since intervertebral discs at this age are already significantly dehydrated and lose the ability to invert retraction.

Hydroplasty, which, unlike cold plasma, laser or radio wave nucleoplasty, is based on the destruction of part of the nucleus pulposus by the pressure of a physiological solution. The operation is also performed through a puncture of soft tissue. The solution is fed through a conductive needle, which additionally has a branch for aspiration of waste material. The effect of hydroplasty is similar to the results of nucleoplasty and also consists in the reverse retraction of the protrusion.

But if an MRI has already detected a rupture of the fibrous ring of the disc, i.e. the formation of a true hernia, nucleoplasty loses its relevance. In such cases, it is usually necessary to resort to microdiscectomy, endoscopic surgery, and others.

What factors cause disc protrusion?

Most often, the key cause of the disease is osteochondrosis. The appearance and progression of the disease also contribute to:

Physical inactivity, prolonged stay in one position (drivers, office workers, etc.);
Violation of metabolic processes;
Increased loads on the spinal column associated with sports activities or heavy physical labor;
Weakness of the muscle corset;
Spinal injury;
Overweight;
Pathological change in the configuration of the spine;
Disorders associated with aging of the body;
Wrong diet.