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The diagnosis for bulging and herniated discs can frequently be faulty because MRI scans upon which doctors and surgeons rely can only show about 25% - 40% of the patient's condition - and even then the results of such scans are not necessarily indicative of the real problem affecting the patient. Scans can assist but they cannot provide conclusive evidence of a particular condition. A patient for example may not exhibit any symptoms that might be expected from the scan, and vice versa, so it is necessary to take the history, pathology, and range of movement into consideration, which is beyond the field of study of most general practitioners and surgeons. In cases of 'torn' muscles or ligaments, it is uncommon for soft tissue to be actually torn: it is more often simply compressed. If passive movement of the joints is impaired by even a tiny misalignment of a joint, the soft tissues and ligaments will go into spasm, which occurs in the majority of cases. The patient might then feel that he has 'torn' a ligament, which is not actually the case. The nerve roots from the spinal cord are 2/3mm thick, while the distance between the discs and the spinal nerves is 1.2/1.5 mm. The height of each disc in the lumbar region is 9mm, in the thoracic 6mm and in the cervical (neck) 3mm. The spinal nerves can control muscular, motor, or sensory functions or a combination of these - and if effected by a misalignment of a joint or otherwise, the patient will develop a range of different types of pain with tingling or numbness in different parts of the body such as an arm, hand, finger or toe. Treatment The gentle rythmical pressure of mobilisation, which is applied chiefly with the aid of the tips of the thumbs, cures the herniation and resolves the disc to its proper position, by causing the pulposus to 'suck' back into the centre of the disc. The larger the protrusion the more time it will take to return. The outer rim is affected in the majority of cases and following treatment, it will take up to three months to heal. If a herniation is not treated in a timely manner, the outer rim of the disc will become scarred, and unable to heal properly, which will then result in a weaker disc. From the age of 60 the discs lose about 20% of their water content and their ability to recover from a hernia is less, but surgery for this condition is unnecessary and always extremely dangerous at any age, because eventually the neighbouring joints are subjected to constant irregular pressure which can cause pain and stress fractures. These joints are normally strong precisely because they are supported by surrounding ligaments and tissue, which include the spinal discs, and these should be left intact to serve their purpose as best they can. A herniated or bulging disc can impinge on other nerves such as the sciatic nerve, causing sciatica or severe pain in the leg, thigh, buttocks, hip, feet and toes. If upper sections of the back are affected then symptoms will appear in the arms, hands or fingers. The symptoms will determine exactly which disc is affected, and although the condition is very painful, surgery is never required to cure a herniated or bulging disc, and should not be performed, as any relief obtained by cutting away the nucleus pulposus pressing against a nerve is in reality merely a temporary and barbaric 'solution' (although the procedure is a good revenue earner for the hospitals that carry out these operations). This condition creates fissures and cracks in the rim of a disc which can then lead to herniation (when the nucleus pulposus is exposed or displaced through a crack or tear in the disc's rim) and the results of the disease also create a chain reaction of alterations in the bio-mechanical structure of the spinal column. The condition can be caused by prolonged and irregular pressure on the discs due to the patient's poor posture and bio-mechanical deformities (such as a short leg). After the age of 60 when even normal discs lose up to 20% of their water content, they become prolapsed (thinner) and are not as elasticated as before. Remnants of the nucleus pulposus known as debris can then adhere to the sides of nerve sleeves causing pain and Degenerative Disc Disease often combines with other conditions such as osteophytosis or sponyltitus (cracks in the pars intervertebralis). Treatment The bio-mechanical derangement in the spinal column and the normal function of the lumbar spine can be restored by mobilising the joints to free them from constrictions and by rectifying any actual or impending herniations. Any fissures or cracks in the discs will then heal up over three months, but they must be made to heal in their proper place, which is why treatment is essential. Following treatment, the patient is required to undertake regular and specific exercises to strengthen appropriate muscles. This is a layman's term used to describe a common back problem and as such it is not a clinical definition of any specific condition. Sciatica is related to the sciatic nerve which is the thickest and strongest nerve in the body. The nerve can sustain a hanging weight of 700kg (the weight of 7 adult men) before breaking. The roots of the Sciatic nerve control motory, sensory and mixed functions via the bones, muscles and skin and it divides into two sections which pass down from the spine, through the hips, into each leg. Since none of the nerve roots correspond physiologically, different types of pain can be produced; e.g. a dull ache is felt in bone, numbness (acroparisthesia) in skin, and sharp pain in muscle - and of course these symptoms can overlap. The Sciatic nerve is in close proximity to adjacent discs (1.2-1.5 mm) which is why so-called discongenic pain can arise. This pain however is caused by the tethering or rubbing of the nerve sleeve, and not by the discs themselves, while compression of the nerve doesn't necessarily cause any pain. As a result of mechanical friction affecting any of the nerve roots, the condition can become inflammatory which is extremely painful. If not treated properly this will lead to scarification in the area around the inflamed sleeve which in time would result in devascularisation (reduced blood supply to the veins). The body reduces the supply of blood to certain veins if parts of the body are scarred and no longer require it as much as when the tissue was healthy. This process, which occurs as a result of the condition and also as a consequence of surgery, often produces referred pain along those nerves which are affected. Treatment As a general guide regarding the symptoms of sciatic pain, the hip and groin are supplied by nerves from the L1 level, the thigh by L1 and L2, the knee by L3, the hamstring by L4; and the calf, ankle and foot by L5 and S1 (affected in 85% of cases). The treatment of sciatica is easily carried out by decompressing the sciatic nerve at the affected joint level in order to remove the source of friction against the nerve. Relief from pain is felt after only a few sessions when neuro-muscular and skeletal functions are restored. The straight-leg raising test (Lasague Test) can give a good indication of the level of compression required and which section of the spine is causing the problem. As with any chronic nerve root impingement it can several months for the nerve to rejunvenate properly and for numbness to completely subside, as nerves rejuvenate at the rate of 24 hours per millimetre of nerve. Spinal surgery (discectomy) is often performed with a view to removing some or all of a disc to relieve pressure on the sciatic nerve. However, the consequences of weakening the stability of the spinal column by removing or fusing discs together causes much more harm than the original condition, and is entirely unneccessary when the same result can be achieved in a few weeks of physical thereapy. The key to success (as with all physical therapy) is in finding a practitioner who is qualified and experienced in treating this condition. This can be caused either by hereditary or developmental factors (metabolic, habitual postures, lack of exercise etc). There are over 80 types of scoliosis and some causes are unknown (ideopathic). Curvatures up to 40 degrees can be treated non-surgically but the condition should be arrested as soon as possible by non-surgical treatment. It can be treated through spinal mobilisation, making the condition symptomless through a specific set of spinal exercises which will strengthen the underdeveloped group of muscles. Specific exercises (all of which are carried out while lying down) will cause further growth in the musculo skeletal system that will balance the scoliosis. The main purpose of mobilisation is to re-align the spinal column joints as much as possible and to decompress the nerve roots and soft tissues. Scoliosis becomes worse when changing position, as stresses and strains are altered, so the tendency for the patient is to lie down for relief (body pressure on the spine is 25% of the weight when lying down on the back with knees bent). The body pressure increases depending on the posture: sitting can produce an average pressure of 80/100 kg on the lumbar spine; standing 100-120kg; while sitting and bending forward for writing can produce 140kg. The spine is obviously weaker with scoliosis, and the balance of spinal fluids can change considerably (causing homeostatic osmosis in the cerebrospinal fluid). This results in general fatigue, depression, exhaustion, stress, headaches, irritability and organ dysfunctions. Treatment Mobilisation is essential to open the articulations (joints) of the spine and to restore their passive mobility (movements of the joints themselves). A regular program of active muscular exercises can be then be set for the patient when the passive mobility of the joints have been restored as much as possible. Surgery for this condition always produces scar tissue which becomes semi-necrotised. Every single muscle consists of strips of tissue material (except the heart which contains smooth muscle tissue) and every surgical incision produces local devascularisation or de-oxygenation which leads among other things to muscle spasms. Stenosis (narrowing) can affect both blood vessels and the spinal canal. In the case of cardiovascular stenosis, fatty deposits resulting from metabolic disorders give rise to a narrowing of the vessels, while in spinal stenosis, the narrowing of the spinal canal can be caused by four factors: (i) Heredity (ii) Development (iii) Degeneration (iv) Trauma. Cardiovascular stenosis often co-exists with spinal stenosis and is particularly common in older patients. Usually the patient can walk up to 100 metres without difficulty, but then problems such as severe cramps in the calf can appear. When spinal stenosis is caused by heredity or developmental factors, the shape of the canal can be triangular or the neural arcs in the vertebrae can fail to develop properly (as in spondylothesis). A collapsed disc may give rise to stenosis and if it is an anterior herniation (generally caused by a physical trauma) then this would be one of the rare cases requiring surgical treatment. Spinal stenosis caused by degeneration is usually limited to the L4/L5 level and often affects women who are 50yrs old or more. The condition can easily affect the root canals of the spinal nerves and not just the column. Osteophytosis which results in a growth of the bony spurs of the spine usually on the posterior part of the vertebrae can also give rise to stenosis. In older patients however, a natural stiffening of the vertebral column can paradoxically make the condition asymptomatic. Treatment Some conditions are dormant and asymptomatic and therefore care must be taken before acting on the results of MRI scans or x-rays which can often give a false impression as to the causes of the patient's pain. If surgery is carried out based on the results of such scans (and it often is), it will not provide any cure if in fact the patient's pain is due to some other cause. The general approach to treatment is to test the mobility of the joints at the affected levels and to ascertain whether the pain is localised or referred. Secondary symptoms such as numbness, temperature of the limbs, muscular weakness and other neurological deficit can guide the correct approach to be adopted. The passive mobility of the affected joints must be restored physically for each of the six possible ranges of movement: flexion, extension, lateral flexion either side, and rotation. Sometimes in order to treat a complicated condition and depending on the pathology of the case, a manual or mehanical method of traction can be applied to lengthen the spine after mobilisation has been carried out. This all helps to reduce neurological symptoms so that the patient for example can walk more easily. Repetitive traction is mistakenly carried out in some hospitals but this should be avoided because it can cause hyper-mobility in the joints. The patient is asked to practice specific spinal exercises to strengthen the abdominal muscles which help to control (50%) of the stability of the spinal column. It is to be noted that lumbar disc herniations and spinal stenosis have different clinical symptoms, while stenosis may sometimes be caused by a tumour or an aneurysm. Surgical methods attempt to restore the stability of the affected area using decompressive laminectomy (see our links section for more information on this procedure). In our experience spinal surgery for this condition is counter-productve. This condition is characterised by a forward slipping (anterior displacement) of one or more vertebrae that invariably results in stenosis of the spinal canal. Slippage can occur if the adjacent ligatures are weak, which is often the case in the lumbar area, particularly is people live a sedentary life style. There are five main causes of displacement: 1. Displastic 2(a) Stress fracture (b) Acute fracture 3) Elongated intact pars interarticularis 4) Degenerative or trauma which can apply to different parts of the vertebrae 5) Pathological (tumour/vascular discorders etc). There are also four levels of displacement possible : Level 1 (25% slippage which is not regarded as serious and where mild symptoms are not too troublesome - patients do not like to stand or sit upright for long and are adverse to lifting objects). Level 2 (50% slippage which causes a lot of pain and stiffness as the dura is tightened, and which is commonly associated with a herniated disc.) Level 3 (75%) Level 4 Complete displacement which is very dangerous as this could cause paralysis through total obstruction of the spinal canal. Treatment X-rays should be carried out when the patient is standing to correctly ascertain the extent of displacement, and any physical examination is carried out in the same way. Palpation always shows a small indentation in the patient's back at the point of displacement, which can even be visible in the surface tone of skin depending on the level of degree. When the patient lies down with knees bent at 90 degrees, the indentation is no longer palpable because in the lying position the spine is naturally decompressed by 25% and the vertebrae are able to re-align of their own accord. Although mobilisation can be carried out for all levels of displacement, manipulation is always contra-indicative for this condition and must never be conducted. Any level of displacement up to level 4 can be successfully treated non-surgically, although surgery may have to be considered if the patient is obese (as the spine is under more pressure), and may also be necessary if the condition is found to be progressive over a three - six month period. Depending on the patient, anything from grade 2 may require surgical fusion to stabilise the joint. In all cases where non-surgical treatment is possible, the condition is treated symptomatically depending on the spinal areas affected, keeping in mind that the lower or supporting vertebra is always stiffer as a result of the displacement. In conjunction with treatment, a specific set of exercises are given to build up the muscles of the trunk. The patient is however never allowed to raise their legs because this action causes the spine to become elongated. Strengthening exercises are a mixture of isotonic (repetitous) and isometrical (maintaining tension). Swimming is beneficial, but not contact sports or horse riding, and running on a soft surface is also feasible for an otherwise healthy patient experiencing only minor displacement. The largest joints in the spine are L4 and L5 and as these sustain the most pressure they are affected in 65% of all cases. Between 30%-60% of cases are linked to accidental trauma of some kind. This condition produces stress fractures in the pars interarticularis parts of vertebrae and arises as a result of a deformity or trauma. The L5 and S1 joints are mostly affected and attendant lesions are usually found in 5% of the population. The ligamentum fluvum (supporting ligaments of the vertebrae) become thicker and soft tissues are produced in a larger quantity affecting the local vascularity and nerve supply. All the biomechanics of the segment become affected and bone density can alter resulting in stiffness and less mobility of the affected joints. It is mainly a developmental condition which often produces Spondylolesthesis. Extensions and lateral flexion causes an increase in the sheer stresses on the pars interarticularis, but after the age of 20 the spine responds to the condition by forming its own means of stability. It is commonly seen in female gymnasts and for some reason football lines-men and soldiers who have regularly carried back-packs. Research has shown that patients who do not walk much are seldom affected. Surgery is considered if mobility or gait is impaired, the purpose being to provide stability by fusion to keep the affected vertebrae solid. However, bone density decreases with old age and therefore relapses can occur requiring further operations. The visceral organs near the level of the spine affected can also seemingly be affected when displacement occurs, producing for example 'kidney pain' when the organs themselves are perfectly healthy. Treatment It is essential to directly increase the mobility of the affected joints and indirectly the soft tissues without causing any direct rupture of the tissues themselves (which although thick are nevertheless for this condition useful for containing the condition). No manipulation should be conducted for this condition because further slippage or damage can be caused - and this applies particularly to chronic cases. If there is any segmental instability due to repetitive trauma through movement then stress fractures may occur which can heal of themselves but it is important to help them heal in a proper alignment. This is achieved through a combination of treatment modalities such as mobilisation, ice packs, and isometric exercises. Treatment as always must be preceded by an accurate diagnosis of the specific condition. This involves degenerative changes in the invertebral joints which is marked by a narrowing of intervertebral spaces. The treatment involves mobilisation and varies with each condition. A trapped or compressed nerve can arise from sudden movement or any minor injury, and while the condition is troublesome causing pain, numbness or tingling in the arm, hand or finger etc, the condition is easily treated by mobilisation: gentle oscillatory movement applied at the correct spinal level by an experienced practitioner usually cures the problem completely by freeing pressure on the nerve. Pain killers and muscle relaxants will obviously never be able to free a trapped nerve. Sometimes manipulation is performed to break up adhesions (swathes of bonded flesh that have built up over time causing stiffness and devascularisation, and which affects nerves, resulting in pain). Surgery is often performed quite needlessly to free a trapped nerve, and the results are always much worse than before the operation. It can safely be said that for the vast majority of spinal conditions surgery is neither necessary nor effective, as it almost always leads to long term complications and suffering for the patient, out of all proportion to the original condition. The use of metal rods, screws and plates and the cutting away of parts of the spine, even the heating of discs to cause them to shrink (IDET procedure) represent a rather crude approach to the treatment of spinal problems and is not a method of 'treatment' that we can ever recommend. The procedures of Orthopaedic Medicine outlined above do not involve operating on a patient, and all treatment is safe and manageable as well as being highly effective.
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