4 Treating the discs

The discs act as flexible cushions between the spinal vertebra during mechanical shear and loading, cushioning the spine and giving it flexibility. Discs have an inner gel-like nucleus surrounded by an outer covering, the annulus fibrosus, wrapped in 13 concentric laminated bands around the nucleus, not unlike a jelly doughnut wrapped around its jam filling. The well-innervated disc annulus has no vascular supply and receives its nutrients by diffusion from the vertebral body vascular supply where it attaches to the end plates (White 1978). The disc is an osmotic system sensitive to load, pressure and concentration of proteoglycans that lives from motion (Kraemer 1995).

Water flows out of the disc during compression while standing or sitting upright and flows into the disc during decompression from relaxed sitting and lying. The disc itself has no blood supply and its nutrition is by diffusion from the end plate vasculature. To be optimally healthy the disc must be hydrated and mobile but not subject to excessive static compressive or repetitive flexed rotational loading. Inflammation in the disc is a response to excessive or prolonged loading, dehydration and micro tears in the annulus.

The outer three annular layers of the healthy disc are innervated by small myelinated and unmyelinated nerve fibers from the dorsal root ganglia and sympathetic trunks from multiple spinal levels. A disc at one spinal level may receive innervation from three or more spinal levels which means that inter-neurons in the cord are also involved. The vertebral end plate is as well innervated as the disc annulus suggesting that the end plate is an important source of discogenic pain (Lotz 2006).

The muscles at the spine stabilize the segment and protect the disc and the joint during movement. If the muscles are not effective the joint moves too much, the annulus is overstressed and the rate of degeneration increases: “… degeneration occurs as the result of imbalance of both static and dynamic spinal stabilizers. The disc degeneration that occurs is characterized by increased local inflammation and increased apoptosis of intervertebral disc cells” (Wang 2006).

The disc nucleus is rich in phospholipase A₂, a strongly proinflammatory substance that is very toxic and damaging to nerves (Olmarker 1993, 1995, Ozaktay 1995, 1998). When the disc bulges or ruptures the fragments of the nucleus expand from hydration when they are outside annular containment. The disc fragments create inflammatory damage to the nerves, the disc annulus and the surrounding tissues which is compounded by the immune system inflammatory response to a foreign body in the epidural space.

Degeneration is an inevitable response to mechanical loading and shear during repetitive motion or constant static loading as the spine ages. Studies have shown increases in IL-1, IL-6, TNFα and PGE₂ in injured discs. TNFα stimulates nerve growth factor and causes pain sensitive nerves to infiltrate the outer layers of the disc annulus and become sensitized. The degenerative process in the discs is complex and characterized by inflammation, loss of water and elasticity, tearing, scarring and disorganization of annular fibers, infiltration of nerves into the degenerated annulus and end plate tissues and dehydration and fragmentation of the nucleus (Kang 1996).

Pathologic degeneration may be a chronic ineffective healing response consisting of ongoing accumulation of tissue damage in the end plate and disc annulus, inflammation, neo-innervation and nociceptor sensitization. Physiologic degeneration on the other hand may be an adaptation to loading over time, without accumulation of peripheral damage and thus having no appreciable inflammatory or nociceptive component (Lotz 2006). Patients with genetic predisposition to increased inflammation have increased degenerative response to activities that compromise disc health (Solovieva 2004). This genetic predisposition, when combined with environmental factors can create enhanced inflammatory response and may explain the difference between two patients with identical spinal imaging showing disc degeneration when one patient has tremendous pain symptoms and one has no pain at all.

Medical treatment for disc related injuries and pain includes pain medication, steroids to reduce the inflammatory response, physical therapy, exercises to stabilize the spine and move the disc fragment away from the nerve root as recommended by McKenzie (2006) and ultimately surgery. Epidural steroid and “caine” class anesthetic injections are used to reduce the nerve pain and inflammation and to keep the patient comfortable while the disc heals. Cauda equina symptoms, such as loss of bowel or bladder function, and severe motor weakness are indications for open spinal surgery without delay.

Microsurgery has better outcomes than large open back surgeries. It produces less perineural scarring because there is less muscle trauma, less internal bruising and fewer layers of tissue that have the potential to adhere to each other. Failed back syndrome, iatrogenic spine, or post-discotomy syndrome (PDS) result from the inflammation, soft tissue scarring and perineural fibrosis that accompany surgery.

Ultimately, if the pain can be managed and the surgery is put off long enough the symptoms resolve on their own and fewer than 10% of patients presenting with discogenic and radicular pain require surgery. Only 0.25%, one quarter of one percent, of individuals with “back problems” requires some form of surgery (Kraemer 1995).

Most surgeries are performed to provide pain relief for patients in the acute phase of disc inflammation. FSM has been shown to be effective in reducing neuropathic pain (Chapter 3) and in reducing IL-1, IL-6, TNFα and COX and LOX mediated inflammation, all of which have been implicated in discogenic pain. If FSM can be used to reduce inflammation and pain along with exercise therapies in the 99.75% of back pain patients who do not require surgery, more patients can recover function and avoid surgery and its complications. There are numerous case reports in which FSM treatment has done exactly this. The responses are consistent, predictable, reproducible and very encouraging to both patients and clinicians treating this difficult patient population.

Figure 4.1 • A normal healthy disc is a flexible hydrated osmotic system that depends on the vertebral end plate vasculature for its nutrient supply. To be optimally healthy the disc must be hydrated and mobile but not subject to excessive static compressive or repetitive flexed rotational loading. Inflammation in the disc is a response to excessive or prolonged loading, dehydration and micro tears in the annulus

(adapted with permission from White & Panjabi 1978).

Figure 4.2 • The degenerated disc is mechanically different from the healthy disc. The disc nucleus is dehydrated and fibrosed and the protein polysaccharide content is altered from normal. The annulus is hardened and scarred from previous repairs of repeated microtrauma and may have one or more tears that allow the nucleus to protrude or extrude outside annular containment. The vertebral end plate is hardened and calcified impairing circulation to the disc. All of these factors change the load bearing characteristics of the disc and contribute to accelerated degeneration. Degeneration progresses along a continuum and depending on general health, hydration, physical activities and mechanical stresses and may accelerate, slow or in some cases even reverse

(adapted with permission from White & Panjabi 1978).

Diagnosing the disc

Treating the disc with FSM is usually successful but the practitioner must know that the disc is what needs treating, which is not always as obvious as it sounds. The key to diagnosing discogenic pain is in the history, especially the mechanism of injury, the pain patterns and physical examination.

The mechanism of injury will involve flexion or combined flexion and rotation or some activity that exposes the patient to axial loading, lifting or flexion and rotation on a regular basis. In general, spinal flexion or combined flexion and rotation make the pain worse and extension may make the pain better as long as the patient does not have co-existing facet joint degeneration. Some patients know exactly what activity created the injury and some patients have no idea. Some patients have a history of activities that challenge the disc and then experience one event that makes the disc symptomatic. The challenge in taking the history is to identify which activities create spinal loading, flexion and rotation and might have caused the injury by asking questions about specific activities.

The patient may complain of low back, neck, shoulder, or thoracic spine pain or dermatomal nerve pain depending on what level has been injured and how badly it has been damaged. Some patients will have pain only in the area of the inflamed nerve root and their complaint will be “leg pain in the lateral calf” and not an L5 disc injury. Treating the leg or the muscle will not be satisfactory since the disc is ultimate the cause of the leg pain.

Cervical discogenic pain may present as neck, shoulder and arm pain or midscapular pain. The classic diagram (Fig. 4.3) published by Cloward describes the midscapular referred pain areas for the cervical discs. The patient with a cervical disc injury may present only with midscapular pain and shoulder pain (Cloward 1959). Treating the shoulder or the midscapular area will be unsatisfactory and only treatment aimed at the cervical disc will relieve the symptoms.

Figure 4.3 • The cervical disc annulus refers pain in between the shoulder blades stepwise down the spine according to the levels injured. The presence of mid-scapular pain helps diagnose the presence of an injured disc as the cause of neuropathic pain. It should be kept in mind that there are nine muscles, seven thoraco-costal joints and seven cervical facet joints that also refer to the midscapular area

(adapted with permission from Cloward 1959).

History questions

• What sorts of things were you doing in the days or weeks just before the pain started?

Look for activities that require flexion or combined flexion and rotation such as golf or tennis, yard work, laying floor coverings, painting, or moving.

• Were you lifting, leaning forward while using a keyboard, sitting, driving or bending over for long periods?

• Did you have any sort of trauma such as a fall or traffic accident?

Side impact accident force vectors put the discs at special risk especially if the spine is in rotation at the traumatized segment at the time of impact.

• Were you in one flexed or rotated position without moving for a prolonged period of time?

One patient fell asleep for 6 hours sitting up with his head tilted over to one side compressing the disc annulus and causing a small disc bulge that was read as “normal” on an MRI. The ensuing severe neck, shoulder and arm pain was clearly disc and nerve related but he waited 2 years for a diagnosis because his physicians didn’t connect the mechanism of injury with the vulnerability of the discs to compression, rotation, connective tissue creep and shear. In 2 years no one had done a sensory examination.

• What do you do for a living?

Truck drivers, heavy equipment operators or workers who use equipment that vibrates while they are sitting have accelerated rates of degeneration in the discs and facets. The precipitating injury that is the “final straw” may seem minor but it will always involve axial compression, flexion or flexion and rotation. The most commonly degenerated discs are at L5–S1 but any lumbar disc can be at risk.

Data processors, secretaries, dental assistants and dentists, watch repairmen and violinists work in positions that put the neck into chronic prolonged flexion and rotation. These professions come to mind but any profession with similar biomechanical challenges is at risk for discogenic disease.

• What do you do for fun or do at home?

People who work in the yard or garden and who pull weeds by hand, who lay stones, or who dig holes or trenches with picks or shovels subject the spine to intense compressive forces with the neck and low back in a flexed position. People who work on cars often find themselves lifting heavy loads in awkward positions or working in one flexed position for prolonged periods of time. Some sports such as golf or tennis exert ballistic rotational forces on the discs that create chronic micro-injuries and eventually tissue failure.

How much does it hurt?

The pain level in acute discs is usually moderate to severe 5–8/10 on a 0 to 10 visual analog scale (VAS) tends to be worse when the muscles spasm to protect the area and worse with provocative activities. Chronic discogenic pain may be rated somewhat lower at a 3–4/10 VAS with pain excursions into the 5–8/10 level with provocative activities.

Where does it hurt?

The discs themselves have fairly well defined pain patterns creating pain at and near the spine. Cervical discs refer in between the shoulder blades as discussed above. If the disc injury creates minimal muscle spasm and just irritates the nerve the only symptom may be mild neuropathic pain in the dermatome adjacent to the injured disc. The L5–S1 disc is said to refer to the coccyx and is often mistaken for coccydynia. The L4–5 disc refers pain to the ischial tuberosities.

Nerve pain patterns

Sometimes isolated nerve pain is the only symptom that a disc has been injured. If the mechanism of injury or the patient’s activities do not account for the pain, it suggests that an evaluation of the nerve and the discs would be worthwhile.

• C3: refers pain to the slope of the neck along the trapezius muscle and the patient may say they cannot tolerate a necklace or any clothing touching the neck

• C4: refers pain to the point of the shoulder and can mimic shoulder joint injury

• C5: refers pain into the upper arm

• C6: refers pain to the thumb and the lateral elbow

• C7: nerve root refers to the medial elbow

• Thoracic nerve roots: refer pain onto the chest or abdomen depending on the level affected

• L1: Lower abdomen

• L2: Groin, hip or upper thigh

• L3: Medial thigh and knee

• L4: Medial calf and ankle

• L5: Lateral calf, great toe and area between the first and second toe

• S1: Heel and lateral edge of the foot

• S2: Posterior leg

• Pudendal nerve: refers pain to the pelvis, genitals and groin through S2, S3, S4.

Muscle pain patterns

Muscle in the shoulder girdle is innervated by the C5 or C6 nerve roots. The nerve irritation creates taut muscles and the taut muscles may develop myofascial trigger points which have their own pain patterns referring into the arms and hands. The practitioner is referred to The Trigger Point Manual for complete listing of trigger point referral areas (Travell 1983).

Every muscle in the hip and low back is innervated by branches of the L3 nerve root. Disc related nerve irritation causes the muscles to become taut and eventually to develop myofascial trigger points. The trigger point referred pain patterns overlap the referred pain patterns from the discs and nerves and can complicate the diagnostic challenge. In some cases the trigger points are the only symptom and the perpetuating factor is the disc injury and inflammation (Travell 1992). Treating the muscle gives temporary relief and only treatment aimed at the disc will provide lasting improvement.

What makes it better – What makes it worse?

Flexion / combined flexion and rotation

The inability to tolerate flexion postures is diagnostic of disc injuries. The patient may complain

Figure 4.4 • This dermatome chart is only one of several versions of dermatomal sensory distribution commonly used. There are individual differences among patients and the sensory diagram is an approximation of nerve distribution in any given patient. Record the findings from the sensory examination on the dermatome diagram noting hyperesthesia, normal findings and reduced or absent sensation.

specifically that the pain is worse when driving a car because the seats put the lumbar spine into flexion and the legs are extended while using the pedals. This position creates flexion pressure on the discs, and stretches the sciatic nerve causing pain in the foot, leg or hip.

Patients with lumbar discogenic pain cannot lay supine with the knees flexed and must have the legs straight when supine so the lumbar spine is in extension. The patient can usually lay prone comfortably as long as the facet joints are not also pain.

Cervical discs create neck pain and pain between the shoulder blades and in the cervical dermatomes that is worse with forward head postures created while using a keyboard, eating or reading. The pain will be worse when lifting or using the arms outstretched because the anterior cervical muscles contract to stabilize the spine during lifting, causing disc compression.

Headaches, neck, arm and hand pain will be worse with certain sleeping positions when a pillow creates neck flexion. Driving a car places the neck in flexion because of poor seat design and holding the steering wheel with the arms outstretched creates nerve tension and muscle fatigue making this activity a guaranteed pain generator for a cervical disc patient.

Valsalva

The pain may be worse with a bowel movement, sneezing or coughing because these activities increase abdominal pressure and increase pressure on the disc, exposing the nerves to increased inflammatory products from the disc. If neck, arm or hand pain or low back or leg pain or trunk and abdominal pain increases with coughing, sneezing or bowel movements it suggests that the disc is involved.

Imaging

The most common imaging for a disc is a CT or MRI; x-rays are not useful for disc injuries. Both CT and MRI will reveal a badly herniated disc. The challenge is in discerning the damaged inflamed disc that is a pain generator but appears as a “disc bulge” that is read as “normal” because it is not herniated outside the annulus and is consistent with the degeneration expected for the patient’s age. A small piece of the nucleus may herniate but still be contained by the annulus. The inflammation will make the annulus appear very dark and the small piece of nucleus appears as a small white speck just inside it. The very well innervated annulus will become a strong pain generator but the disc will appear “normal”. Imaging has limitations of resolution and cannot detect the microscopic internal changes in the disc that make it a pain generator. There is no way to tell from the imaging alone whether a disc is a pain generator. The imaging must be correlated with the clinical picture and physical examination.

Evaluating disc injuries

Most practitioners reading this text have been trained to perform a physical examination to evaluate the spine for discogenic injuries and pain. This brief description is meant to be a reminder rather than a comprehensive instruction. It is included to reinforce the notion that FSM treatment must match the diagnosis. The patient may present with a diagnosis of “disc injury and sciatica” but it is best if the practitioner confirms the diagnosis.

Evaluation of a disc injury through physical examination is done directly by physically challenging the disc, and indirectly by interrogating the sensory nerves, the spinal cord, the reflexes and the motor nerves which may be compromised by the inflammatory material released from the injured disc.

The reader is encouraged to pursue more complete instruction in physical examination techniques and orthopedic assessment.

Physical examination

The disc can be directly challenged by maneuvers that physically compress it or stress it in the direction of lesion. Cervical discs can be evaluated by gently pressing on the top of the head and loading the discs in axial compression. If a disc annulus is compromised the maneuver will cause pain between the scapulae (Cloward 1959) and may increase pain in the affected dermatome.

A Valsalva maneuver, in which the patient inhales, holds the breath and bears down, will compress the injured disc and move nerve towards the inflamed area causing local and occasionally dermatomal pain.

Nerve tension tests gently stretch the nerves and are painful when the nerve is inflamed due to disc injuries. They are non specific but can be revealing when combined with the history and other findings. Straight leg raise (SLR) is a nerve tension test for the L4, L5 and S1 nerves.

Dermatomal sensory exam

If the disc is injured the nerves and occasionally the spinal cord will become inflamed. Sensation in the nerve roots may be normal, numb or hypersensitive. In patient terms, the sensation created with a pin or pinwheel will be prickly and sharp (normal), dull (reduced) or very sensitive and unpleasant and “icky” (hyperesthesia). Nerves usually become hypersensitive long before they lose function and become numb.

A dermatomal sensory examination is performed by gently stroking a pinwheel, a pin or some sharp object such as a paper clip across the skin of the dermatome. All dermatomes, C2 through S3, should be tested to determine the sensory status beyond the area of pain complaint to evaluate for multiple levels of disc injury, more widespread central sensitization or spinal cord involvement.

Reflexes

Reflex testing is done with a brisk strike of a reflex hammer to create a brisk tendon stretch to evaluate the reflex arc associated with nerve root being interrogated. If the nerve root is not seriously compromised the reflex will be brisk, normal and rated +2/4. A normal deep tendon reflex does not mean that the disc is uninjured it only suggests that the disc is not likely to require surgery.

If the nerve is more seriously compromised the reflex will be reduced or absent at the level of the injured disc. Reflexes that are hyperactive below the level of the injured disc are as revealing as reduced reflexes. A deep tendon reflex has normal brisk amplitude because descending inhibitory impulses from the brain reach the segment in time to dampen the reflex arc. If the spinal cord is inflamed above the level of the reflex being tested the inflammation slows conduction in the cord and prevents the inhibitory impulses from reaching the segment in time and the reflex below the injured level will be hyperactive. A hyperactive patellar reflex indicates inflammation in the spinal cord at some level above L3 but is not specific as to what level. The best indicator of a cervical disc injury is a hyperactive patellar reflex. Analysis of the complete physical examination will usually reveal the precise level involved.

Muscle testing

Muscle testing is done by isolating the involved muscle and gently loading it to determine strength. If the muscle “locks and holds” when loaded it has full strength (+5/5). If it contracts but doesn’t “hold” against testing pressure it is somewhat weak (+4/5). If it is unable to hold against any pressure it is weak (+3/5). And if it is unable to lift against gravity it is significantly weak (+2/5). The reader is referred to Hoppenfeld (1976) or a similar physical examination text for a more complete description of muscle testing and evaluation.

Loss of motor function (+3/5) suggests serious neural compromise and a surgical consult is advised even if the patient is going to be treated conservatively.

Myofascial involvement

The biomechanical abnormalities of the spinal segment associated with disc degeneration can contribute to the formation of myofascial trigger points in the muscles and fascia. Trigger points cause the muscles to be short and taut and contribute to the compression and loading of the discs and facets that accelerates the degenerative process.

Myofascial trigger points sensitize pain nerves that feed back into the spine. This neural input from the muscles compounds the nociceptive sensitization of the nerves to the disc from the dorsal rami and amplifies the pain response. Palpation of the muscles in the lumbar spine will almost always reveal trigger points in the psoas, quadratus lumborum and multifidi, most prominently at the level of the involved disc.

In the cervical spine, the scalenes, longus coli, levator scapulae, sternocleidomastoid (SCM) and trapezius will usually have trigger points in the area directly adjacent to the involved disc. Palpate the deep scalenes between the thyroid cartilage and the SCM and feel a taut band just along the border of the anterior disc line. This taut band is an indicator that the disc at that level is inflamed. When the disc is treated the band should soften and disappear as treatment progresses.

When discs in the thoracic spine are inflamed the thoracic paraspinals and trapezius directly adjacent to the disc will be taut and may contain trigger points; digestion may be affected. The rectus abdominus may be taut and have trigger points at the levels whose nerves are affected by the injured disc.

The practitioner treating a disc patient will of necessity end up treating the disc, the nerve and the muscles associated with that disc.

More than one diagnosis

Patients who have both facet and disc generated pain will have pain with both flexion and extension and may have trouble finding a relief position. Specifically, it is common in patients who have had whiplash injuries to have a C5–6 disc injury from the flexion component that creates neck and shoulder pain and a C2–3 facet joint injury from the extension component that creates upper cervical pain and a peri-orbital headache. As the patient flattens the cervical curve to relieve the upper facets the disc annulus compresses and the patient begins to experience discogenic midscapular and nerve pain. The patient will arch the neck to relieve the disc pain until the facet compression in the upper cervical spine becomes intolerable. The patient constantly shifts neck position from flexion to extension to obtain relief from one or the other of the pain generators. If the spinal ligaments were damaged in the same injury the pain may be quite intense.

Patients with chronic low back pain may have pain generators in the disc annulus, the facet joints, the muscles and the nerves. The same injuries that traumatize and damage the discs can also damage the muscles and facet joints. The psoas attaches to the anterior vertebral bodies and the discs and the lesser trochanter in the femur and acts as a trunk and hip flexor. Lumbar flexion may be painful because of a disc injury or it may be painful because trigger points in the psoas are activated when the muscle contracts to flex the trunk but the presence of trigger points in the psoas does not rule out the disc as a pain generator in lumbar flexion. The facet joints may cause pain when compressed during lumbar extension or the trigger points in the psoas may be activated when stretched during extension. The patient may have the disc, the muscle and the facet joint all contributing as pain generators.

As always the patient is entitled to more than one diagnosis. FSM practitioners have tools to treat each of these conditions and the only challenge is figuring out which to treat first in any given patient or whether to treat them all simultaneously (see Chapters 5, 6, 7, 11).

Treating spinal discs

Hydration

• The patient must be hydrated to benefit from microcurrent treatment.

• Hydrated means 1 to 2 quarts of water consumed in the 2 to 4 hours preceding treatment.

• Athletes and patients with more muscle mass seem to need more water than the average patient.

• The elderly tend to be chronically dehydrated and may need to hydrate for several days prior to treatment in addition to the water consumed on the day of treatment.

• DO NOT accept the statement, “I drink lots of water”

• ASK “How much water, and in what form, did you drink today before you came in?”

• Coffee, caffeinated tea, carbonated cola beverages do not count as water.

• Water may be flavored with juice or decaffeinated tea.

Channel A: condition frequencies

The frequencies listed are thought to remove or neutralize the condition for which they are listed except for 81 and 49 / which are thought to increase secretions and vitality respectively. They are listed alphabetically not in order of use or importance.

• Calcium ions	91
• Chronic inflammation	284
• Hemorrhage or bleeding	18
• Inflammation	40
• Scarring	13
• Sclerosis	3
• Secretions (Increase)	81
• Torn or broken	124
• Vitality (Restore)	49
• The basics
remove trauma	294
restore function	321
remove histamine	9

Channel B: tissue frequencies

• Disc as a whole: ___ / 630

This frequency is thought to address the entire disc structure.

• Disc Annulus: ___ / 710

The well innervated disc annulus is the most pain sensitive and most easily injured portion of the disc. It consists of coiled layers of sturdy connective tissue wrapped around the gel like nucleus. This tissue frequency responds best to treatment.

• Disc Nucleus: ___ / 330

The gel like disc nucleus fills the center of the disc and absorbs water to become a cushion for the vertebral bodies in the spine. It is very high in PLA₂ and very inflammatory.

• Dermatomal or Peripheral Nerve: ___ / 396

Any nerve outside the spinal cord

• Spinal cord: ___ / 10

Conducts impulses between the nerves and the brain

A/B pair for Inflammation

40 / 116

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