Spine Pain and Rib Conditions

Disc Problems/Herniated Disc

The most common reason to visit our Tulsa Chiropractor is spine pain, and the most common reason for spinal pain is related to problems with the disc. I would like to take some time to explain the basics about these intervertebral discs. Be sure to look at the pictures above for reference.

There is a disc between each vertebral bone in the spine. The disc is basically a shock absorber. It is very much like one of those gel inserts you put in your shoe. The outside consists of rings of rubbery material (the annulus) and the inside is a gelatinous liquid (the nucleus). The design provides for mobility and shock absorption that reduces stress to the spine. However, if enough stress occurs to the disc, it can start to cause damage usually resulting in a tear in the annulus.

There are several patterns of disc tears. Tears can occur through the annulus or between the fibers of the annulus. If the tear is bad enough, the nucleus can begin to migrate from the center position into the tear which causes an abnormal shape of the disc. This abnormal shape interferes with the movement of the spine. You may notice painful restricted motion. You may notice spasm or a shifting/leaning of your spine. When the shape of the disc is distorted, but the nucleus has not yet migrated outside of the confines of the disc, we call it a Disc Bulge.

This Problem can continue to worsen. At the point where the nucleus travels past the outermost layer of the disc, it becomes a Herniation. There are a variety of other terms used to describe differing shapes and phenomenon that can occur with herniations including: protrusions, prolapses, and sequestrations, but we won’t get into those here. So, the take home point is that damage to the disc over time will create these disc bulges and herniations that result in a change in shape and position of the disc material. This in and of itself is painful enough, but there is an even more significant problem that can occur. It can lead to compression of the nerves in the spine!

The spinal cord goes from the brain down through the center of the vertebra and exits the spine right next to the disc in branches called nerve roots. From the spine, these nerves travel to different parts of the body to control sensation, muscle function, and some other things. This system allows your brain to communicate with your body. For example, the nerves that control your legs begin in the brain, travel down your spine, exit out of your low back, then go to your legs. If a disc herniation is compressing these nerves, it interferes with the signal. This can create pain, numbness, tingling, spasm or weakness in your legs: Boom…sciatica!

Disc herniations can compress nerves of the spine in two main ways: nerve root compression, and central cord compression. The herniation can poke out to the side contacting the nerve root, or it can herniate centrally putting pressure on the cord. Pressure on the cord is by far the worst scenario. This can even be life threatening if it occurs in the right place. It could also cause paralysis, loss of bowl or bladder control, and a variety of other terrible issues. This can sometimes be surgical emergency. Thankfully, this is not the most common form. What we usually see is that the disc material herniates out to the side and contacts the nerve root rather than the cord. This can happen in the neck causing pain to shoot out into the shoulder, arms, or hands along with weakness and numbness or spasm of the muscles. It can happen in the low back as well causing the same sort of thing to happen in the buttocks and legs. This is actually the cause of most cases of sciatica.

As the process of disc injury continues, the disc begins to whither and desiccate causing loss of disc space. This creates another situation that we call degenerative disc disease (DDD), which can also lead to narrowing of the space that the nerve needs to exit the spine. If this space is narrowed to the point that it compresses the nerve, we call this stenosis, and it can cause the same sort of nerve problems that a herniation can create.

So, what can a Chiropractor do to help you with your disc issue? A Chiropractor’s job-first and foremost- is to identify which type of disc issue is occurring, and determine whether physical medicine is safe or if you will need surgery. If it’s safe, then we can correct the position of your spine with a variety of different treatments. This will take the stress off of the disc and stop the process of the disc herniation from continuing.

Once the position is corrected, the disc can have a chance to heal especially with the right nutrition. A Chiropractor will usually perform spinal manipulation to correct the position and movement in your spine. This typically brings a lot of relief. I like to use electro-muscle stimulation to calm down the muscles and reduce pain either locally or down the affected limb. Additionally, traction or decompression can be used to take the pressure off of the disc and centralize the nucleus to reduce the herniation. Once the pain is under control, I use progressive rehab techniques to train the muscles of the body to hold the spine in the correct position. This step is important to stabilize the joint so the problem doesn’t just come back the next time you bend over to pick up a pencil.

Sciatica

Signs & Symptoms

If you have experienced low back pain with shooting pain down your the back or side of your leg, then it just might be sciatica. Other symptoms include numbness, tingling, altered sensation, and weakness. Usually one leg is affected, but it is possible to have both legs involved. If both legs are involved this can be a more serious sign (cauda equina syndrome), especially if there is loss of bowel/bladder/sexual function or loss of sensation of the inside of the thighs. Sciatica is not really a specific diagnosis and can have a variety of causes. You might also call sciatica a “pinched nerve”. Where the nerve is being pinched and what is doing the pinching is more complicated. As you might know, the different nerves in your low back go to different places in your legs. The affected area of the leg depends on which nerves are being damaged. The middle nerves of the lumbar spine tend to affect the front of the leg, lower nerves of the lumbar spine tend to affect the side of the leg, while nerves of the upper sacral spine tend to affect the back of the legs. Another sign of sciatica is that symptoms travel below the knee. This indicates a truly neurologic pathology that has a high risk of chronicity. I want to mention here that the term sciatica is derived from the sciatic nerve, but sciatica is often used simply to refer to spine pain or leg pain. This can sometimes cause confusion. For the sake of this article, I will include several conditions which can present with these symptoms, but are not actually sciatica.

Disc Pathology

Vertebral discs can change shape or even herniate. A disc bulge is a change in the shape of the disc. A herniation is when the gel-like center of the disc protrudes out of the normal confines of the disc. These changes in the disc can end up putting pressure on the nerves of the spine. The disc can herniate left, right, or center. Down in the lumbar region a central disc herniation can lead to a condition called Cauda Equina Syndrome that is serious and requires immediate surgery in order to prevent permanent loss of bowel/bladder/sexual dysfunction. A herniation to the left or right will likely put pressure on the nerve root. The symptoms depend on the amount of irritation/ pressure and the level of the disc. Disc pathology is the most common reason for sciatica and is considered the cause in the classic definition of true sciatica.

Spondylosis and Spinal Stenosis

Degenerative joint disease, degenerative disc disease, and osteoarthritis together are lumped into the term spondylosis when they occur in the spine. Spinal Stenosis is the term used to indicate narrowing of the passageway of the nerves. Spondylosis can lead to spinal stenosis. The loss of disc space narrows the diameter of these nerve passageways from top to bottom, and bone spurs can narrow the passage ways from front to back or side to side. Disc and bone changes can also narrow the diameter of the spinal canal (where the cord and several nerve roots exist) causing Cauda Equina-like symptoms. Additionally, people are sometimes born with already narrow nerve passage ways and this puts them at even greater risk of developing sciatica and other related neuropathies. Of course, anything that changes the shape, alignment in the spine can lead to stenosis such as pregnancy, Scheuermann’s disease, or scoliosis.

Other Space-Occupying Lesions and Pathology

Some more serious reasons for sciatica are tumors, fractures and infections. These situations warrant immediate medical intervention. A tumor grows and occupies space that can put pressure on nerves. Fractures may lead to bone fragments putting pressure on nerves and/or cause instability of the spine that results in nerve compression. An infection can also create changes and inflammation in the spine that can lead to these sorts of neuropathies. These pathologies are the first things that should be ruled out during an initial examination.

Piriformis Syndrome

There is a particular muscle in the buttocks called the piriformis. The sciatic nerve runs right under this muscle. A tightening or contracture or over development of this muscle (usually compensation for gluteal weakness) can put pressure on the sciatic nerve. In a small portion of the population, the sciatic nerve travels either partially or entirely through the piriformis muscle. If the piriformis is chronically contracted, then it can strangle the nerve producing sciatica. However, piriformis syndrome is traditionally not considered true sciatica.

Femoral Neuropathy

While true sciatica tends to occur from pressure of the nerves in the lower lumbar spine, nerves can also be irritated in the same way in the upper part of the lumbar spine. When this occurs, the fibers of the femoral nerves can be involved instead of the sciatic nerves. In these cases, pain is typically felt in the front of the thigh instead of the back/side of thigh. The underlying causes are pretty much the same as sciatica, just in a different place affecting a different group of nerves.

Meralgia Paresthetica

This is a condition where the lateral femoral cutaneous nerve (a nerve that runs down the outer thigh) can be compressed or injured. This has been nicknamed the “skinny pants syndrome” because tight fitting pants or belt is the underlying cause (one of the reasons I recommend elastic/stretchy material). The nerve becomes entrapped around the front of the hip and groin region as the nerve passes from the pelvic area to the outer thigh. Motor vehicle accidents can also cause lesions of this nerve from contact of the seat belt. There are several other less common causes for compression and injury to this nerve. This condition is also not included in the classic definition of sciatica.

Iliotibial Band Syndrome and Trochanteric Bursitis

This is another biomechanical issue that can cause pain running down the leg with occasional neurological implications and can be associated with back pain. See the section on Hip Pain for more detail. There is a muscle called the tensor fascia latae (TFL). Tightening of the TFL can create excessive tension of a band of fibrous connective tissue that runs down the outside of the leg called the iliotibial band (ITB). This tension puts pressure against the trochanteric bursa which is located around the hip bone. This whole complex of problems is referred to as ITB syndrome and trochanteric bursitis and they usually occur altogether. Pain often starts in the hip and travels down the outer thigh to the knee. Muscle spasm, swelling, and general tension can lead to nerve compression occasionally. This makes the problem look like sciatica, but again, this is not true sciatica.

Herpes Zoster

Ever had chicken pox? This is caused by the varicella zoster virus. Like all other herpes viruses, it actually lives in your nerves imbedding itself into the DNA of the nerve cells. It is there forever. It is usually dormant but can become active again leading to herpes outbreaks. When chicken pox reactivates, it is called herpes zoster or commonly “shingles”. This typically happens to older adults but can happen in younger people too. Before the full rash appears, a person can have neurological symptoms including pain and numbness. If the affected nerve is in the low back and leg, then this virus can present just like sciatica, and so I’ve included this condition in this section.

General Kinetic Chain Dysfunction

In some cases, pain can appear to shoot down the leg with back pain not because of a pinched nerve, but because of a problem in the kinetic chain. A kinetic chain is the link between several consecutive joints and the muscles and other soft tissue involved in that linkage. It is a head-bone-is-connected-to-the-foot-bone situation. Here is an example: A patient has a “flat foot” that rolls inwards. When that foot rolls inwards, it causes the knee to also travel inwards. This drops the pelvis on that side. This causes the lumbar vertebra to tilt. Many muscles and ligaments are stressed because of these postural changes. This leads to pain in the back and the leg. Voilà!!! Kinetic chain dysfunction… not sciatica.

Further Considerations

As you can see, sciatica is pretty complicated. I haven’t listed all of the conditions that can cause low back pain with leg pain, but I’m guessing your head is already spinning. These different problems can look like true sciatica, but only a trained physician can correctly diagnose the real issue. Sometimes it is a serious problem that requires immediate medical attention. Sometimes it requires surgery. Sometimes surgical intervention will not fix anything. To compound the problem, studies have shown that MRIs are not as reliable as we once thought. Things like degenerative changes and disc herniations appear all the time in completely asymptomatic patients. The older we are, the more likely we are to have these findings on imaging, but that likelihood has very little association with the symptoms that we experience: it is simply a coincidental finding. Likewise, there are many people who experience what appears to be true sciatica upon clinical examination but have no findings on MRI or X-ray! For those of you who are interested in a reference, I can point you towards Rehabilitation of the Spine: A Practitioner’s Manual: Chapter 14 (this is considered the rehab bible by many physical medicine practitioners).

Treatment

Despite all of the confusion and all of the controversy, there are established guidelines for treatment of sciatica. This is my synopsis:

1. Treating sciatica with medicine like muscle relaxers, anti-inflammatories, and pain killers is an appropriate intervention on a preferably temporary basis, but it should be understood that medicine does not address the underlying biomechanical dysfunction. Though, it can help to ease the symptoms while the body heals. I myself sometimes refer patients to medical doctors when symptoms are severe enough. Medicines that calm pain and muscle spasm actually help me to do my work as it decreases guarding allowing me to more easily manipulate and rehab my patients. I like to communicate with my patient’s primary care physician anyways, so we can be on the same page. Cooperation is important.
2. Sciatica that does not self-resolve in a few weeks should first be treated conservatively. This includes things like manipulation, physiotherapies, rehab, massage, and manual therapies. I also perform a few injections with naturopathic/homeopathic medicines here in the office as I am certified and licensed to do so.
3. If conservative therapy has absolutely no effect by two weeks, then I either change the plan, or possibly seek advanced imaging like X-ray or MRI. I do not allow patients to remain without progress in the clinic. If I really can’t get results, I refer out to a different specialist.
4. If conservative treatment is initially effective, but we reach a plateau after a time, then advanced imaging is warranted if not previously obtained along with a possible referral for surgical consult. Though sometimes it is necessary for insurance purposes to first refer back to the patient’s primary care physician. This is another reason it is good to be in communication with the patient’s PCP.
5. If I do refer out for surgery, the doctors usually only perform surgery after it is established that steroid injections or other less invasive medical intervention also fails.
6. I prefer that patients and their surgeons consider less invasive surgeries that do not involve the use of hardware in the spine. Long term outcomes tend to be poor for these more invasive surgeries (though sometimes there is no other option). The addition of hardware means that the involved sections of the spine are immobilized resulting in stress of the vertebra above and below, and often lead to further surgery of those sections down the road.
7. If surgery fails, then patients are typically referred to pain management clinics.

The healthcare community is well-aware of the opioid epidemic and nobody wants the final outcome to be simply mitigating symptoms with pain killers and other medications. The point is that conservative therapy should come first. If this fails, then more aggressive medical measures should be taken.

If you think you might have sciatica, please make an appointment with our chiropractor in Tulsa today.