“My disc is bulging out, please put it back in Doc!” must be one of the most over-utilised statements in everyday practice at every chiropractic clinic!
After all, when it comes to the treatment and management of spine related disorders, chiropractors are positioned at the top of the hierarchy, just below spine surgeons.
The metaphor we give to our experience of acute/chronic low back pain is purely based on socio-cultural conditioning. Although we cannot visualize the disc bulge/protrusion, we give it a defined label – “bulging out”. Metaphors make it very easy for us to bring clarity and meaning to the complexity of what processes are going on at the level of the spine. What if this metaphor no longer serves a purpose or is associated with other cognitive/emotional or behavioural states?
What if I was to tell you that disc bulges/protrusions can actually spontaneously resolve on their own and may have no direct correlation to the pain that we are experiencing?
It was previously thought that once a disc bulges or protrudes outside it’s confined space, that it never resorbs. However, a study conducted of 9 patients with a disc protrusion showed that spontaneous resorption of herniated disc material was found in all patients in an average time of 9 months. All patients recovered clinically in a mean time of 6 weeks by conservative treatment (chiropractic and rehabilitation care).
The above MRI images show changes that have taken place over a 9 week period of time – note in the top rows of both images (A and B in Image 1 and A, B and C in Image 2) where the extrusion is visible (blue arrows) and how it has naturally resorbed over time in the images in the second row (C and D in Image 1 and D, E and F in Image 2).
Similarly below, this neck MRI in Image 3 below shows spontaneous regression of nuclear material after only 3 weeks – A, B, C and D in the top row showing the protrusion and in the second row( E, F, G and H) showing the resorption :
What are the mechanisms for Intervertebral disc resorption?
- Retraction of herniated disc because it is not separated from annulus fibrosis
- Dehydration and shrinkage of the herniated NP with higher water content
- Sequestrated NP in epidural vascular space is recognized by the autoimmune system as a foreign body, which induced an inflammation reaction resulting in neovascularization, rapid enzymatic degradation and macrophage phagocytosis. This is more apparent with large sequestrated disc material.
It is interesting to note that large and/or sequestrated discs bulges were associated with rapid resorption. Patients who recovered earlier, showed early spontaneous resorption. Interestingly, large herniated discs resorbed spontaneously faster than smaller herniated discs due to higher water content and its exposure to the epidural space with wide surface area. Furthermore, modic changes of endplates (see featured heading image – whitish appearance localised by my pen) may affect the rate of spontaneous resorption, but size and shape of intervertebral disc protrusion are more powerful predictors of spontaneous resorption!
So, is the resorption of the intervertebral disc necessary for reduction in pain intensity?
The recovery of radicular pain not only depends on reduction of size of herniated disc material but also on improvement in inflammation, oedema, and congestion by conservative treatment. So, in other words, reductions in oedema, inflammation and congestion by appropriate nutritional supplementation, chiropractic care and the prescription of exercises from a neuro-centric approach will reduce pain to a greater extent than the process of disc resorption itself.
There are at least 3 things for you to take into consideration when discussing about that nature of your MRI report:
- First, Lumbar disc herniation can regress or disappear spontaneously without surgical intervention.
- Secondly, Disc extrusion and sequestration are more prone to regress than disc bulge and protrusion (77% versus 30%).
- Finally, Disc sequestration had a significantly higher rate of complete regression than did disc extrusion (43% versus 15.0%).
Of course, there are a few factors which can limit the spontaneity of disc resorption. Together in practice, these factors can be discussed to lessen the emotional and psychological burden created by the idea of the common metaphor “My disc is bulging out, please put it back in doc!”
Watch the videos below to understand the mechanisms for disc resorption: