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Herniated Disc

Nick Cotta

Coach Kramer

Advanced Sports Medicine; Per. 2

17 May 2017
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Introduction:

A herniated disc happens to be a common condition that people encounter that can not be

reversed. Other names for a herniated disc include a ruptured or slipped disc. For a herniated disc

to develop, one of the discs which is a cushion-like pad between the vertebrae shifts out of

position and applies pressure on the adjacent nerves. Typically herniated discs are caused by

overuse or trauma to the spine, however other factors may include normal aging or a genetic

factor which contributes to the development of disc degeneration leading to a herniated disc. If

rest, medication, and physical therapy fail to treat the injury then surgery may be needed.

Discs are cushion like pads that absorb force or stress put on the vertebrae. The discs are

located between each vertebrae and prevent the bones in the spine from grinding against one

another. The two main uses for discs are to absorb the impact of trauma and support a persons

body weight. A disc has two layers, the outer layer is called annulus fibrosus and the middle

layer which is a gel-like center, called nucleus pulposus. On the outside of each disc there are

fibers that attach the disc to adjacent vertebrae and hold the disc in place. When these fibers

begin to deteriorate along with the outer layer of the disc, the gel-like center begins to leak into

the spinal canal. Unfortunately, the spinal canal only has enough space to contain the spinal cord

and spinal fluid. When the gel-like center of a disc leaks into this canal, it causes compression on

the nerves or on the spinal cord. Inside of the disc, the gel-like substance releases chemical

irritants which contribute to the inflammation and cause the individual pain and discomfort.
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II. Review of the Literature

A. Anatomy

Bones

The spinal column of a human is made of up 33 bones in total which consists of 7

vertebrae in the cervical region, 12 vertebrae in the thoracic region, 5 vertebrae in the lumbar

region, 4 vertebrae in the sacral region, and 4 vertebrae in the coccygeal region. The cervical

region consists of C1-C8 which contains the Atlas (C1) and the Axis (C2). The Atlas is the first

vertebrae at the top of the spinal column and forms a joint which connects the skull and the

spine. The Axis has a strong odontoid process which rises perpendicularly from the upper

surface of the body. Next is the thoracic vertebrae which consists of T1-T12 and increases in

size. The thoracic vertebrae is located between the cervical vertebrae and the lumbar vertebrae.

The thoracic vertebrae also provides attachment for the ribs and make up part of the thorax.

Usually fractures to the spine are most common in the thoracic and lumbar regions or at the

connection between the two. The lumbar vertebrae also increase in size from L1 through L5. The

lumbar vertebrae bear the majority of the bodys weight and related biomechanical stress. The

lumbar vertebrae are also the largest segments of the moveable part of the vertebral column. The

Sacrum consists of four or five vertebrae in a child which eventually become fused into a single

bone after the age of 26. The sacrum helps form the back wall of the pelvic girdle. The first three

vertebrae of the sacral region have transverse process that come together to form wide lateral

wings which are called alae. At the very bottom of the spinal column is the coccyx which

consists of 3 to 5 bones that are fused together as an adult.

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Ligaments

There are three major ligaments within the spine which are the Ligamentum Flavum,

Anterior Longitudinal Ligament and the Posterior Longitudinal Ligament. The Ligamentum

Flavum forms a cover over the dura mater which is a layer of tissue responsible for protecting

the spinal cord. It connects under the facet joints and creates a small curtain over the posterior

openings between the vertebrae. The Anterior Longitudinal Ligament attaches to the front of

each vertebra and runs up and down the spine. Next is the Posterior Longitudinal Ligament

which runs up and down behind the spine and on the inside of the spinal canal. The cervical

region consists of the Alar, Anterior Atlantoaxial, Posterior Atlantoaxial, Ligamentum Nuchae,

Anterior Longitudinal, Posterior Longitudinal, and Ligamentum Flavum. The Alar ligament is

located at the Axis and limits head rotation and lateral flexion. The Anterior Atlantoaxial

ligament and Posterior Atlantoaxial ligament are located at the Axis and Atlas. The Anterior

Atlantoaxial ligament limits extension while the Posterior Atlantoaxial ligament limits flexion.

The Ligamentum Nuchae ligament is located at the cervical and limits flexion. The Anterior

Longitudinal ligament, Posterior Longitudinal ligament and Ligamentum Flavum ligament are

all located from the Axis to the Sacrum. The Anterior Longitudinal ligament limits extension and

reinforces the front of the annulus fibrosis while the Posterior Longitudinal ligament limits

flexion and reinforces the back of the annulus fibrosis. The Ligamentum Flavum limits flexion.

The thoracic region consists of the supraspinous ligament which is also located in the lumbar

region and limits flexion. The lumbar region consists of the Interspinous and Intertransverse. The

interspinous limits flexion and the Intertransverse limits lateral flexion. The sacral region

consists of the Iliolumbar, Sacroiliac, Sacrospinous, and Sacrotuberous ligaments which are all
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located at the sacroiliac joints and limit stability and some motion. The Occiopitoatlantal

Ligament Complex (Atlas) consists of four ligaments that run between the Occiput and the Atlas

which are the Anterior Occipitoatlantal ligament, Posterior Occipitoatlantal ligament and two

Lateral Occipitoatlantal ligaments.The Occipitoaxial Ligament Complex (Axis) consists of four

ligaments which connect the Occiput to the Axis. Those ligaments include the Occipitoaxial

ligament, two Alar ligaments, and the Apical ligament. The Atlantoaxial Ligament Complex

(Axis) consists of four ligaments that extend from the Atlas to the Axis and consist of the

Anterior Atlantoaxial ligament, Posterior Atlantoaxial ligament, and two lateral ligaments.

Finally the Cruciate Ligament Complex consists of the Transverse ligaments, the Superior

Longitudinal Fascicles and the Inferior Longitudinal Fascicles which help to stabilize the

Atlantoaxial (Axis) Complex.

Muscles and Tendons

The muscles of the back either individually or in groups are supported by fascia which is

a strong connective tissue. The tendon that attaches the muscle to bone is part of the fascia. In the

thoracic region of the back there are three major muscles which are the Longissimus Thoracis,

Iliocostalis Thoracis, and the Spinalis Thoracis. The Longissimus Thoracis and Iliocostalis

Thoracis both assist with the extension and lateral flexion of the vertebral column and rib

motion. The Spinalis Thoracis helps extend the vertebral column. The lumbar region of the back

consists of the Psoas Major, Quadratus Lumborum, and the Multifidus. The Psoas Major flexes

the thigh at the hip joint and the vertebral column. The Quadratus Lumborum assists with lateral

flexion of the vertebral column and the Multifidus assists with the extension and rotation of the

vertebral column.
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Bursae

A bursa is a fluid filled sac that is usually located within a cavity. Within the spine, there

are bursae sacs in between each vertebrae. The bursae consists of the annulus fibrosus and the

nucleus pulposus. The annulus fibrosis is the outer layer of the bursae and surrounds the softer

inner core which is the nucleus pulposus. The annulus fibrosus consists of ligament fibers which

helps the annulus fibrosus prevent the leaking of the nucleus pulposus which leads to a herniated

disc. The nucleus pulposus is at the core of the intervertebral disc and is composed of mainly

water and some collagen fibers. It is the nucleus pulposus that provides the cushioning between

the vertebrate of the back.

Nerves

The most complex part of the spinal column is the nerves. There are a total of 31 nerves

located within the spine which consist of both motor and sensory nerves. The ventral side of the

spine is where the motor nerves begin while the sensory nerves are located in the posterior root

ganglia. Each region of the spine consists of a certain number of nerves. The Cervical region

consists of eight pairs of nerves, the thoracic region has twelve pairs, lumbar region has five

pairs, sacral region has five pairs and then one pair is located in the coccygeal region. All of the

nerves that are located within those regions serve as a pathway to the central nervous system.

Those nerves also help the hypothalamus with the secretion of hormones and the sympathetic

system which is responsible for the fight or flight reaction.

Blood Vessels

The blood vessels just like the nerves are also complex and help with blood flow

throughout the spine. There are a total of 20 blood vessels located within the spine. Those blood
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vessel consists of the, thoracic aorta, arterial plexus, venous plexus, posterior vein, anterior

radicular vein, posterior radicular vein, posterior intercostal arteries, pinal branch, sulcal vein,

anterior segmental medullary artery, anterior radicular artery, anterior spinal artery, right

posterior spinal artery, left posterior spinal artery, posterior radicular artery, anterior spinal vein,

lateral cutaneous branch, medial cutaneous branch, sulcal arteries, and the dorsal branch of the

posterior intercostal artery.

B. Kinetics

The 24 vertebrae of the back are divided into four groups, cervical, thoracic, lumbar, and

sacral. In between each vertebrae is a disc that acts as a cushion and the vertebrae are connected

by small muscles that are called multifidi. The motion of the spine is measured in degrees of

range of motion. All movements start at 0 degrees which is a neutral position that consists of

standing up straight, arms to your side and eyes straight ahead. The four movements of the spine

that are measured are flexion, extension, lateral flexion, and rotation. The cervical spine supports

and enables a person to move their head. It is made of up seven vertebrae and has a lordotic

curve. Flexion in the cervical spine is dropping your head to your chest which normal range of

motion is 45 degrees. Extension of the cervical spine is dropping your head back and looking

upwards which normal range of motion is 45 degrees. Dropping your ear to your shoulder

measures lateral flexion which normal range of motion is 45 degrees. Finally the normal range of

motion for rotation is 80 degrees both directions. The thoracic region of the spine is made up of

12 vertebrae and has a kyphotic curve. For the thoracic region, flexion and extension should both

have a normal range of motion from 20-45 degrees while lateral flexion range of motion should

be between 20-40 degrees. The lumbar region of the spine is made up of five vertebrae and has
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the same curve as the cervical spine which is a lordotic curve. The normal range of motion for

flexion is 90 degrees and for extension 30 degrees. The normal range of motion for lateral

flexion and rotation in these regions is 30 degrees. For the sacral region, the normal range of

motion is between 5 and 15 degrees. The average total mobility should be around 9 degrees.

C. Classification of Injury

The spine of a human can experience skeletal and soft tissue injuries. The skeletal

injuries include compression fracture, burst fracture, flexion-distraction fracture,

fracture-dislocation, stable fractures, unstable fractures, minor fracture, and major fracture. All of

these fractures are commonly experienced due to high-energy trauma. Many of the soft tissue

injuries are classified as strains which can limit mobility depending on the location of the strain.

Injuries to the nerves of the spine also happen to be common due to the amount of nerves located

within the spinal column. Injuries to the lower back which includes the lumbar and sacral regions

often result in some loss of function in the hips and legs and little or no voluntary control of

bowel or bladder. Injuries to the thoracic nerves may also result in little or no voluntary control

of bowel or bladder or paraplegia. The upper thoracic nerves affect muscles, the upper chest,

mid-back, and abdominal muscles. Injuries to the lower cervical nerves may result in a loss of

control in the arms or hands and weakened breathing. Injuries to the high cervical nerves are

more serious than others and may result in paralysis in arms, hands, trunk and legs, impaired

speech, loss of bowel and bladder control and difficulty breathing. Many of these nerve issues

are caused by herniated discs applying pressure and trapping the nerve within a confined space.

A herniated disc first begins with degeneration which applies a small amount of pressure on the

annulus fibrosis. As the degeneration begins to progress, the disc is now experiencing prolapse
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which, is when there is slightly more pressure placed upon the annulus fibrosis but it is still not

breached. As the degeneration continues, the disc then experiences extrusion which is when the

nucleus pulposus breaks through the annulus fibrosis. Finally the disc reaches the final stage

which is the sequestration phase when the nucleus pulposus begins to leak into the spinal canal.

D. Mechanism of Injury

There are only three ways for an individual to develop a herniated disc. The first possible

way is by degeneration or wear and tear. Our back carries and helps distribute weight while the

discs are meant to absorb the stress caused . Overtime these discs will wear down and the

annulus fibrosis which is the outer layer of the disc can begin to weaken allowing the nucleus

pulposus to break through and leak which in the end causes a herniated disc. The second possible

way is by an injury. A herniated disc can be caused a sudden jerking movement that puts too

much pressure on the disc causing it to herniate. A herniated disc by injury is also possible by

lifting a heavy object incorrectly or by twisting extremely. The third and final possible way an

individual can develop a herniated disc is with a combination of degeneration and injury. A disc

may be weakened over time and then experience a traumatic event which could then lead to the

break through and leaking of the nucleus pulposus causing a herniated disc.

E. Treatment Protocols

The Treatment Protocols for someone suspected of having a herniated disc vary. After an

individual has explained the symptoms being felt and has undergone a physical examination,

imaging may be recommended. Through imaging normal degeneration of the discs are common

to see which means that abnormalities such as a disc being more degenerated than others would

be something to be concerned about. The majority of the symptoms should heal themselves
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overtime which means that rest is a critical part of the healing process. Ice and ibuprofen should

be used to treat inflammation while heat or pain relieving gels can help reduce muscle spasms.

Surgery is only suggested when there is nerve compression causing serious pain or disabilities.

There are a total of five different surgeries that may be approached when dealing with a

herniated disc. The first one is an Anterior Cervical Discectomy and Fusion. This procedure is

performed in the cervical region where a small incision is made in the front of the neck and the

intervertebral disc is removed and replaced with a small plug of bone which will eventually fuse

the vertebrae. The next procedure is a Cervical Corpectomy. This procedure removes a portion of

vertebra and adjacent intervertebral discs which will allow decompression of the cervical spinal

cord and spinal nerves. A bone graft and if needed a metal plate and screws may be used to

stabilize the spine. Next is a Laminoplasty which is a procedure that reaches the cervical region

of the spine from the back of the neck. After the spinal canal is reached, it is then reconstructed

making room for the spinal cord and nerves. The next procedure is one of the more common

procedures which is a Spinal Fusion. This procedure includes instrumentation which includes

cages, plates, screws, and rods and a bone graft to stabilize the spine. There are also different

types of materials used for a bone graft. The three types of bone grafts are the patients own bone

which is an autograft, a donor bone which is also referred to as a allograft, and a bone

morphogenetic protein. The final surgical procedure which may be approached is a Spinal

Laminectomy. A spinal laminectomy treats spinal stenosis by relieving pressure on the spinal

cord caused by a herniated disc. During the procedure a part of the lamina ( part of the vertebrae)

is removed or trimmed widening the spinal canal and creating more space for spinal nerves.
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F. Rehabilitation (Non-Surgical)

Phase I

During this phase, it is essential to control pain and inflammation. Reducing muscle spasms and

establishing pain free positions and postures for sleeping, sitting, and standing are also focused

on. The excercises for this phase are determined on the individual's assessment and will usually

include light stretching with range of motion and core muscle activation. It is important for the

individual to stay slightly active and continue walking and performing activities and exercise that

minimize pain. Activities that cause pain to the area should be avoided.

Phase II

This phase is the sub-acute phase. The goals of this phase are to progressively increase the

patient's activity level and distance walking, improve spinal and low extremity flexibility,

strengthen areas of weakness, and perform abdominal and pelvic stabilization exercises. The

patient should be walking daily and staying as active as possible. They should also be performing

stretches, stabilization exercises daily and lower extremity strengthening three times per week.

Functional movements such as squatting and bending should also be focused on. For core

strengthening and stabilization a quadruped progression, bridge progression, side plank

progression, and a prone plank abdominal progression exercises should be used.

Phase III

This phase is referred to as the rehabilitation phase. The goals of this phase are aerobic

conditioning, restoring spinal and lower extremity flexibility and strength, continuing

stabilization exercise progression and performing functional lifting, bending and reach activities

with only light resistance. In this phase cardio is implemented with walking, jogging, elliptical,
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or swimming. Spinal stretches and lower extremity stretches are essential tp improves range of

motion and flexibility. For strengthening, the quadruped progression, bridge progression, side

plank progression, and prone plank progression should all be continued with the addition of

exercise machines to strengthen spinal musculature, a squat progression, lunge progression, and

exercise machines to strengthen lower extremities.

Phase IV

This phase is referred to as the return to sport/activity phase. The goals of this phase are to

continue aerobic conditioning, return to all functional activities, and achieve maximal strength

and flexibility for return to sport/activity. For this phase, the recommended exercises consist of

daily spinal and lower extremity stretching, aerobic exercise, sport specific aerobic challenges,

multiplanar ball stabilization exercises, and working with gym equipment. Also in the phase the

patient should work with their physical therapist to outline progressive return to sport.

Throughout this phase stretching should be performed daily and held for 30 seconds and perform

2-3 repetitions of each, the cardio program should be progressed in preparation for return to

sport, strengthening exercises should be performed three times a week with 2-3 sets of 15-20

reps.

G. Summary and Conclusion

A herniated disc can be very difficult to deal with. Usually herniated discs occur within

the lumbar region at L4-L5 or L5-S1. The reason that herniated discs are common in this region

is because the lumbar region bears the majority of the bodys weight. Although herniated discs

commonly occur in accidents where a lot of pressure is applied to a specific area or by lifting a

heavy object incorrectly, normal degeneration can also lead to a herniated disc.
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The faster a herniated disc can be diagnosed, the less it can degenerate. When dealing

with a herniated disc, stretching along with strengthening the lower back muscles and core may

help reduce pain that is being caused by the herniated disc. Any exercise or activities that may

include quick movements or twisting may cause pain to reappear. If surgery is needed, the

individual will remain out of any activities for an extended amount of time but the reappearance

of pain is less likely.

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Works Cited

An, Howard S. "Herniated Disc Center." Spine Universe, 25 Aug. 2016,

www.spineuniverse.com/conditions/herniated-disc.

Floyd, R.T. "The Trunk and Spinal Column." Manual of Structural Kinesiology, 19th ed.,

Bookshelf ed., New York, McGraw-Hill Education, 2015, pp. 329-62.

Foster, Mark R. "Herniated Nucleus Pulposu." Medscape, edited by Jeffery A. Goldstein, 3 Feb.

2017, emedicine.medscape.com/article/1263961-overview.

McGinnis, Peter M. Biomechanics of Sport and Exercise. 3rd ed., iBooks ed., 2013.

Newman, Tim. "Herniated Disk: Causes, Diagnosis, and Treatment." Edited by William

Morrison. Medical News Today, 7 Sept. 2015,

www.medicalnewstoday.com/articles/191979.php.

Rostocki, Adam. "What Is a Herniated Disc?" The Herniated Disc Authority,

www.herniated-disc-pain.org/what-is-a-herniated-disc.html.

Scanlon, Valerie C., and Tina Sanders. Essentials of Anatomy and Physiology. 6th ed., iBooks

ed., F.A. Davis Company, 2011.

Simeons, Fauve, and Nele Postal, editors. "Disc Herniation." Physiopedia,

www.physio-pedia.com/Disc_Herniation.
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Appendix

This appendix includes the goals, guidelines and exercises that should be completed

during each rehabilitation phase. Depending on the individual's progression they may approach

certain exercises differently.

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