Question
Dear Dr. Leatherman,
Thank you for your reply. Unfortunately, I have stopped using my treadmill. After much convincing from my Chiropractor, I also had an MRI about 3 weeks ago.(He's been after me for about 4 months). I was told I have a herniated disk (much to my surprise).  I was wondering if you could explain a little bit more about the results:
"L4/L5: There is a 3 mm broad posterior disc herniation with an annular tear.  It flattens the ventral thecal sac.  There is mild narrowing of the posterior thecal sac secondary to mild bilarteral facet hypertrophy resulting in mild central stenosis."
I also have a small herniation at L4/S1 and mild bilateral facet hypertrophy at L3/L4.
I am now on a decompression table and just finished my 8th treatment. Four more to go.  I'm still having the spasms(although not as many) and it has been suggested that I go for an injection where they put the needle right into the nerve? Also, I am 5'8 and weigh 135 lbs.  How much weight should be used on the decompression table to be effective?  Do you think I could get back on the treadmill eventually? I don't want to lose any ground.
Thanks for your time,
Karen

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Followup To

Question -
Dear Dr. Leatherman,
I am a 43 year old woman.  I wanted to lose about 20 lbs. so in March of 2006 I started to run again on my treadmill (I had stopped running a year or two earlier due to 2 torn ligaments in my left ankle and then 2 ankle surgeries to correct the tears). I started having lower back pain on the left side of my spine. I started seeing my wonderful chiropractor who did therapy and adjustments. For the past few months I would have about 30-40 back spasms a day.  The treatments and adjustments were working but not taking away all of my pain due to my treadmill workouts.   This past week I was sent back to have a cortisone injection.  It WORKED!! for about 3 days!  I'm not in the severe pain I once was but the problem is still there.  My PCP and Chiropractor tend to believe that the running is compressing my spine which is causing a trigger point which in turn is causing my back to tighten and go into spasm.  My question is this: I will not stop using the treadmill even though I have slowed down, but should I continue to see my chiropractor on a regular basis so that this won't get any worse or should I just put up with it and just know that it will always be there or wait until the pain is unbearable again?  Right now I only run for 30 minutes at a 11:19 minute mile. I would love to run more but I'm just scared that I will have more spasms again. Any advice on running or Chiropractic care would be helpful.
Thank you for your time,
Karen

Answer -
Dear Karen,

First of all I agree with your PCP and Chiropractic Physician....that the running is creating compression of the spine as well as contributing to the muscle spasms.  Since you've had the two ankle surgeries, the ankle biomechanics are surely compromised which will change knee, pelvis and low back biomechanics and this is contributory as well.  An analysis of your gait (walking biomechanics and posture) is a usefull tool to determine if the problem is originating from running form and/or the lower joints, and not merely the treadmill.  Your chiropractor should be able to perform this evaluation, ask about it...if not a good certified trainer or physical therapist will often have education in gait trainning.  

In relation to the cortisone injection I am glad it worked to control the immediate inflammation and pain.  Cortisone is a great option for short term use.  If there continues to be low level inflammation and pain that is not directly the result of muscle spasm or trigger point, then I would recommend taking Omega Three fatty acids on a daily basis. Actually I recommend it anyway! Look for a product that has EPA (eicosapentanoic acid) and DHA (docosahexanoic acid) and the product must be mollecularly distilled for purity.  5000 to 6000 milligrams per day for the first month and then reduce to 2000 to 3000 milligrams per day for a maintenance dose.  Omegas have many other beneficial health aspects as well, I take them every day.

If you continue to have trigger points and or focal muscle spasms, deep tissue massage is very effective.  We have a certified massage therapist on staff to work with our patients, and she always adds benefits and faster results with chiropractic treatment.  If your chiropractic physician does not have a massage therapist on staff, ask for a referral.

Concerning adjustments, my advice to you is "YES" you should continue on with your chiropractic physcian, with the realization that this will keep the biomechanics of the spine functioning correctly, but it will not control the problem if you continue to run on the treadmill. I don't know how often you are being treated, but a plan of once a week for adjustments is very effective at maintaining low back health along with stretching, range of motion exercises and stability work.  Ask your chiropractor to explain exercises and stretching you can perform at home in addition to his/her care to aid in stability of the low back and pelvis as well as creating flexibility.  If you have not completed a rehabilatory program yet, your chiropractor may want to see you 2-3 times a week for a short period (2-3 weeks).

Concerning your weight loss efforts, brisk walking (long strides)would be much better for you because it decreases the pounding effect on the spine while continuing to elevate the heart rate for cardiovacsular fitness and weight loss. Better yet would be the eliptical machine if you have access to one. You also need to realize that a weight training program will work better to create total body fitness and tone...it may not significantly lower your overall body weight depending on the program, but it will raise your metabolism so that you will burn fat more effectively and for a longer period of time. It is also more effective at sculpting your figure. You don't need any expensive equipment, only a few dumbells and you can perform the exercises at home if you wish.  Form and controlled movements are more important than the amount of weight.  Dumbells of 5, 10, 15, 20, and 25 pounds are sufficient to achieve great results.  Consult a certified personal trainer to learn proper form and exercises if you do not have current knowledge on the subject.

Good luck Karen, keep your head up!
Dr. J. Shawn Leatherman

Answer
Dear Karen,

The disc bulge is when the outer portion of the disc (annulus fibrosis) has worn out somewhat and has lost its structural properties.  When this happens, the inner portion of the disc (nucleus fibrosis) can sqeeze out through the annulus and encroach (push) on the spinal cord.  You are saying that you have a tear in the annulus which is worse than just a bulge.  

The thecal sac is the covering around the spinal cord itself which contains the cerebral spinal fluid that acts as a shock absorber for the spine and also carries nutrition, antibodies etc... for the spinal cord.  

Ventral thecal sac refers to front portion of the cord directly behind the vertebral bodies.  The posterior thecal sac refers to the back portion of the spinal cord near the joints of the vertebra.  The facets are the technical names for the surfaces of joints (zygopophyseal joints) of the vertebral column.  The joints are bilateral structures throughout the spinal column.

Facet hypertrophy is the technical name for arthritic changes inside the joint on the facets themselves.  Central canal stenosis means that the diameter of area inside the spinal cord has been reduced due to the arthritic changes of the spine (more bone growth), and the bulging of the disc.

Going through a decompression program for your symptoms and diagnosis is a good choice.  Are you using the DRX 9000 or the Accuspina decompression table?  These are the two best on the market.  Also according to your height and weight, the decompression unit will be able to calculate the appropriate force concerning the axial pull of the machine, as well as the appropriate angle of pull to concentrate on the L5/S1 & L4/L5 Disc spaces.  Most programs are 20-25 visits on the unit followed by a physical therapy program to strengthen the core spinal muscles that attach to the disc and the facet joint.  The most important muscle in this complex is the "Multifidus" muscle and it should be specifically addressed in your rehabilitation.

Below is a more detailed explanation of disc bulges...herniations.  You can find this exact information on my website at www.suncoasthealthcare.net as well as illustrations of disc bulges.  Just click on the link titles spinal anatomy, and you will also find illustrations that correspond with the above information.

FOUR TYPES OF DISC HERNIATION:

1.  Nuclear Herniation, 2.  Disc Protrusion, 3.  Nuclear Extrusion, 4.  Sequestered Nucleus

        Herniation describes an abnormality of the intervertebral disc that is also known as a "slipped," "ruptured," or "torn" disc.  This process occurs when the inner core of the intervertebral disc, (nucleus pulposus), bulges out through the outer ligamentous layer, (annulus fibrosis).  This tear in the annulus fibrosis causes pain in the back at the point of herniation.  If the protruding disc presses or irritates a spinal nerve, the pain may spread to the area of the body that is served by that nerve.  Between each vertebra in the spine are pairs of spinal nerves, which branch off from the spinal cord to specific areas in the body.  Any part of the skin that can experience hot and cold, pain or touch refers that sensation to the brain through one of these nerves.  In turn, pressure on a spinal nerve from a herniated disc will cause pain in the part of the body that is served by that nerve.

Most disc ruptures occur when a person is in their thirties or forties when the nucleus pulposus is still a gelatinous substance, and most disc herniations will occur in the morning.  The causes of this phenomenon are not entirely known, but are probably due to the physiology of the spine and the changes in the water content of the disc that occur throughout the day.  The two most common locations for a herniated disc in the lower back are at the disc between the fourth and fifth lumbar vertebra (L4/L5) and the disc between the fifth lumbar vertebra and the first sacral vertebra (L5/S1).  These two discs account for over 95 percent of all painful disc herniations.  A disc herniation can occur elsewhere along the spine, but lower lumbar herniations are the most common.

SYMPTOMS

Frequently the patient's main complaint is a sharp, stabbing pain.  In some cases there may be previous episodes of localized low back pain, which is present in the back and continues down the leg.  This is known as sciatica when it goes below the knee.  This pain is usually described as a deep and sharp, and may get worse as it moves down the affected leg.  The onset of pain with a herniated disc may occur out of the blue or it may be announced by a tearing or snapping sensation in the spine that is thought to be the result of a sudden tear of part of the annulus fibrosis.

DIAGNOSIS

Patients with herniated discs usually complain of low back pain that may or may not radiate in the lower thigh or leg.  They will often demonstrate a limitation in range of motion when asked to bend forward or lean backwards, and they may lean to one side as they try to bend.  Neurological and Orthopedic examination performed by a doctor provides the most objective evidence of nerve root compression and may include the straight leg test.  Abnormalities in laboratory test that can detect the presence or absence of a herniated disc, but they may be helpful in the diagnosis of inflammation which can cause nerve root pain and irritation.  An MRI is the gold standard for diagnosis of a herniated disc, but a CT scan (CAT Scan), may often be helpful because it provides better visualization of the bones of the spinal column, indicating where the source of pressure on the nerve root is located.  An EMG, (electromyographic test) may help to determine which nerve root in particular is being compressed or is not normally in the situation where several nerve roots may be involved.

TREATMENT

The treatment for a vast majority of patients with a herniated disc does not normally include surgery.  Eighty percent of patients will respond to conservative therapy when followed.  Treatment is most effective when a patient and their doctor have a good relationship and the patient understands the rationale behind the prescribed treatment.  The primary element of conservative treatment  is controlled physical activity.  Usually treatment will begin with chiropractic adjustments, electric stimulation known as interferential current, and ice for inflammation and analgesic effect.  A short period of bed rest followed by physical therapy and a gradual return to normal activities is appropriate.  Sitting is bad for this condition because the sitting posture puts a large amount of stress and pressure on the lumbar spine, which may increase the pressure on the affected nerve root.  The appropriated use of medication can be an important part of conservative treatment.  This can include aspirin, anti-inflammatory drugs, analgesics, and muscle relaxants or tranquilizers. to aid in pain control.  Surgical treatment is reserved for patients in whom conservative treatment options are not effective and a sufficient period of time has passed to indicate that the patient may need to have surgery for resolution.  A neurosurgical consult is appropriate at that time.

Karen, I know this is alot of information, but I want you to be fully educated on your injury, diagnosis, and treatment.  Be sure to follow-up with your doctors.

Respectfully, Dr. J. Shawn Leatherman