Latest / The Driven Athlete / Herniated Discs - What Now...? | Ep 41

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Herniated Discs - What Now...? | Ep 41 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: What's up?
• 0:12
  Speaker 1: Y'all?
• 0:12
  Speaker 1: It's your man, dr Kyle.
• 0:13
  Speaker 1: Welcome back to the Driven Athlete Podcast.
• 0:15
  Speaker 1: Quick, short one about herniated discs.
• 0:17
  Speaker 1: All right, it's very interesting.
• 0:20
  Speaker 1: Herniated discs are super common right Neck pain and back pain and very rarely less common thoracic spine right the middle back of your spine.
• 0:29
  Speaker 1: So if somebody has back pain and they have pain down their leg right A big trash can term is called sciatica Trash can, being like it collects a lot of things, as in like the sciatic nerve or that region of the nerve is irritated and sending signals right, um, danger signals, right a fire alarm signal, as in like there's something wrong, right, um, and radiculopathy would be referred pain from a nerve root level.
• 0:58
  Speaker 1: That then can cause, at a more extreme rate, um, um, specific muscle weakness, like foot drop right, or in the neck, like thumb and hand weakness, um, and then sensory changes, as in like decreased sense, light touch sensation, like it doesn't, it feels deadened right.
• 1:15
  Speaker 1: So muscle weakness and, uh, sensory diminished symptoms.
• 1:20
  Speaker 1: Um, that would be more like radiculopathy, but referred pain, um and like, uh, there's a little different.
• 1:28
  Speaker 1: That's just pain, nonspecific pain in the glute or down the leg, and I like using the term low back pain, but with referred pain.
• 1:36
  Speaker 1: It's just referred from your low back versus sciatica.
• 1:39
  Speaker 1: Um, yeah, I just I think it's more accurate.
• 1:43
  Speaker 1: All right, sadika is just like that areas you know your nerves involved, right, but referred pain is more, I just think, accurate.
• 1:49
  Speaker 1: So, with that being said, people can have back pain or neck pain with referred pain down the arm, the trap, the shoulder blade, like the middle part of your shoulder blade, down your forearm hand numbness, tingling pins, needles, pain down your glute, down the hamstring region, the back part of your thigh, the groin.
• 2:06
  Speaker 1: And when somebody comes in with back tightness and pain down the groin, the back of the leg, the glute, or down their arm, shoulder, shoulder blade, right, we have to rule out it's not just I'm not thinking hamstring, right, unless they randomly increased their sprints and hamstring curl regimen of their sports or activity, it's usually very commonly our first thought, head and hypothesis goes to back pain, back issues with referred nerve pain, all right, and this referred nerve pain are just signals saying that there's a fire alarm, signaling that there's a danger involved, right, and it's usually referred from the low back, okay, and herniated discs can be a cause of that, but we're finding often it's not the case.
• 2:52
  Speaker 1: It's just interesting, right?
• 2:54
  Speaker 1: So hear me out.
• 2:57
  Speaker 1: Herniated discs are very common, okay, study was showing 70% of people over the age of 43 have some kind of abnormality or disc involvement in their back 70% of people over the age of 43, but you don't see 70% of people getting back surgeries or disectomies or just with back pain, right?
• 3:16
  Speaker 1: It's not that much comparative, right?
• 3:18
  Speaker 1: Otherwise, you would think if there's a structural abnormality, that directly equates to pain and the severity of pain, which is not true.
• 3:26
  Speaker 1: There's plenty of people that have a good looking image on their MRI or x-ray with, like, no herniated discs and the disc levels are normal, but they have severe referred pain, radiating pain on their leg and back pain, spasms and stuff.
• 3:39
  Speaker 1: And then you have people who have not a great looking image and their back is pretty jacked up.
• 3:45
  Speaker 1: There's interval teeple, disc herniations, narrowing of the disc space, degenerative disc disease, degenerative joint changes, arthritic changes, foraminal space narrowing, which is stenosis, ligamentum flavum, inflammation right, ligamentous inflammation, arthritic inflammation, all that stuff Pushing on the nerve root right, and they have no pain.
• 4:05
  Speaker 1: It doesn't make any sense.
• 4:07
  Speaker 1: There's a disconnect between symptoms and the structure, right?
• 4:10
  Speaker 1: So structural abnormality and structural changes don't correlate and connect with the actual symptoms, functionality or prognosis of how someone feels, and these studies just kind of support that.
• 4:20
  Speaker 1: So, that being said, if somebody has a herniated disc like, there's no reason to jump off a cliff.
• 4:24
  Speaker 1: A lot of people have herniated discs.
• 4:26
  Speaker 1: I probably have herniated discs, I'm sure I do.
• 4:27
  Speaker 1: Right, I have intermittent back pain that gets tight occasionally.
• 4:31
  Speaker 1: I played football in college and volleyball, played two sports Like dude, we've done some stuff.
• 4:35
  Speaker 1: I'm sure there's some abnormalities evident, but that doesn't determine or correlate and dictate symptoms or pain, especially for prognosis and future direction, right.
• 4:48
  Speaker 1: So it's just very interesting, all right.
• 4:49
  Speaker 1: So with herniated discs, systematic review of 1100 patients on a lumbar MRI between the ages of 20 to 70 years old 87% of people have evidence of disc involvement, herniations, bulges, whatever.
• 5:03
  Speaker 1: But you don't see 87% of people hobbling around with back spasms, referred pain and then requiring disectomies, right?
• 5:10
  Speaker 1: Systematic review of 3,100 patients on a lumbar MRI 37% of people at the age of 20 had some evidence of disc degeneration, narrowing the disc space, herniated bulging, abnormalities, right.
• 5:25
  Speaker 1: Degenerative changes of the disc 37% of 20-year-olds, but you don't see 37% of 20-year-olds in hobbling back pain right, like spasms, and referred pain down their back.
• 5:35
  Speaker 1: Year olds in hobbling back pain right, like spasms, and referred pain down their back.
• 5:39
  Speaker 1: 96% of people at the age by the age of 80 had evidence of disc degeneration 86%, but you don't see 80, like not every old person has back pain right.
• 5:46
  Speaker 1: I mean 86 is up there, is 80 years old, is up there, right, but not all of them have back pain right.
• 5:51
  Speaker 1: And then 70% of people over the age of 43 have evidence of abnormalities in the spine Arthritic changes, narrowing of the disc space, narrowing of the foraminal openings right, and then ligamentous involvement and inflammation, but not all of them have referred back pain or back pain at all.
• 6:07
  Speaker 1: So there's a disconnect between disc herniations and or abnormalities and actual pain right.
• 6:15
  Speaker 1: And if that's the case, is the disc actually the source and generation of pain?
• 6:20
  Speaker 1: These studies would suggest no, it can be and I don't hate surgery.
• 6:27
  Speaker 1: And if that was the case, then why not just get a disectomy Right now?
• 6:29
  Speaker 1: Problem solved, just fix the structure and your pain will be resolved right.
• 6:33
  Speaker 1: That's not always the case and surgeons are really good at determining that and making decisions.
• 6:38
  Speaker 1: For sure, I don't hate surgery.
• 6:40
  Speaker 1: Sometimes it's necessary, right, and I'll tell a story of a young patient that I had, young being like, early mid twenties, but it's not always the case.
• 6:48
  Speaker 1: Surgery might not be the route.
• 6:49
  Speaker 1: There's plenty of people that have had surgery two surgeries, three surgeries and they're still in back pain.
• 6:54
  Speaker 1: But we fixed everything structurally.
• 6:57
  Speaker 1: Structurally, at this point, everything's good.
• 6:59
  Speaker 1: So then, why are they still in pain?
• 7:00
  Speaker 1: The disc might not be the source of pain, right?
• 7:03
  Speaker 1: So then what is right?
• 7:04
  Speaker 1: I mean nerves.
• 7:05
  Speaker 1: You have nerves everywhere, totally right.
• 7:06
  Speaker 1: You have muscles, ligaments, tendons, bones, the joints, joint capsules, discs, but you also have nerves, and nerves take the longest of anything to heal, and they take a long time and they're very resentful.
• 7:19
  Speaker 1: They have a great memory and they're very sensitive and they take a long time to heal, right.
• 7:23
  Speaker 1: But they do heal and they are the ones that send signals, danger signals, whether perceived, of tissue damage or real tissue damage, perceived or real, they're still going to send signals.
• 7:34
  Speaker 1: They don't know the difference.
• 7:35
  Speaker 1: And they're still going to send signals.
• 7:36
  Speaker 1: They don't know the difference.
• 7:37
  Speaker 1: And they're going to be received, right.
• 7:37
  Speaker 1: And then a decision is made that pain is present, right, but if we can affect those nerves then it'll decrease the pain, right.
• 7:46
  Speaker 1: Like nerves are at a very hypervigilant intensification state of sending signals, like a car radio on full blast.
• 7:52
  Speaker 1: We just got to turn the car radio volume down.
• 7:54
  Speaker 1: And the best way to do that for these nerves is blood flow and movement.
• 8:01
  Speaker 1: Movement to acclimate nerves to movement again so they can be more resilient and less hypervigilant and hypersensitive.
• 8:04
  Speaker 1: And then also blood flow to deliver nutrients and oxygen, because they need to heal and they need oxygen and nutrients, just like any other tissue, to help heal and re-regulate and create a new resting, regulation tone of signaling in addition to the receptors that receive those danger signals.
• 8:22
  Speaker 1: So, with anyway, with all being said, like herniated discs are very common and, with that being said, why not just get a disectomy?
• 8:29
  Speaker 1: There's plenty of people that have and have pain linger even though the structure has been fixed.
• 8:34
  Speaker 1: So then, why is it still hurt Then?
• 8:36
  Speaker 1: Why the disc might not been in the generation of pain, the pain generator, um, or they have pain on the other side of their leg or the other part of their neck, or down their other arm, whatever, right, um, and then getting another surgery to do it again, my yo put the knife down, like it might not be the route right.
• 8:52
  Speaker 1: Let's do some.
• 8:53
  Speaker 1: If we know that the pain generator is coming from a different source, then we can do a different approach to maybe create a benefit and improvement.
• 9:01
  Speaker 1: Right, might not be the route to go.
• 9:03
  Speaker 1: Everything's not so patho-anatomical Patho meaning like pathology.
• 9:08
  Speaker 1: Anatomical meaning structure.
• 9:09
  Speaker 1: There's not.
• 9:10
  Speaker 1: Not everything is a problem with the structure, like that's the pain generator.
• 9:15
  Speaker 1: Not the case.
• 9:16
  Speaker 1: At least that's what the research is finding, and researchers, not me.
• 9:18
  Speaker 1: I'm just relaying information that the research and empirical evidence is finding.
• 9:21
  Speaker 1: That's what they're suggesting, right.
• 9:23
  Speaker 1: So, with that being said, what maybe can we do to improve pain if the structure is not the problem?
• 9:30
  Speaker 1: Right Story about.
• 9:32
  Speaker 1: Sometimes it is, though, and, like I said, I want to tell a story.
• 9:33
  Speaker 1: There's a 26 year old patient I had back in Houston several years ago, and he had referred nerve pain down his leg with foot drop right.
• 9:42
  Speaker 1: His foot wasn't strong, right Like he lost motor function because of the nerve communication.
• 9:46
  Speaker 1: Right.
• 9:46
  Speaker 1: There's different pathways of entrapment or of things that could get involved at the communication, all the way from the spinal cord through the back down the leg and the glute to your leg and your foot to innervate from motor and sensory.
• 9:58
  Speaker 1: So if somebody's having sensory changes and motor dysfunction, like they're not, they're weaker in their foot, like foot drop, um, of course we're thinking, you know there's nerve involvement, totally Right, but what source and how can we intervene?
• 10:11
  Speaker 1: Right, it can be improved without surgery, totally.
• 10:13
  Speaker 1: There's plenty of of of cases and evidence to support improvement with that, without surgery.
• 10:21
  Speaker 1: I don't hate surgery by any means.
• 10:22
  Speaker 1: Right, it's totally necessary.
• 10:22
  Speaker 1: Right, sometimes, but not always and I wouldn't jump into it, at least me humbly, in my own opponent.
• 10:27
  Speaker 1: Of course I'm biased because I'm a physical therapist, but like I would never just be like surgery problem solved, right, like let's dive into the matter and and pursue something and investigate different routes, right, or just at least have a conversation and multiple opinions and whatever.
• 10:40
  Speaker 1: Um, but anyway.
• 10:42
  Speaker 1: So this kid individually, like he had specific referred nerve pain at a specific myotomal and dermatomal pattern, like muscle weakness and sensory change, weakness and diminished sensory and it wasn't getting better, the three things that we think about.
• 10:57
  Speaker 1: If it's like, if it's a true herniated disc that's causing the pain generation and the end of dysfunction, does it hurt with sneezing, coughing and valsalva movements like pressure, sneezing, coughing and pushing, does it hurt with, uh, sneezing, coughing and valsalva movements like pressure, sneezing, coughing and pushing, um, does it hurt in the morning?
• 11:10
  Speaker 1: And then you have hard neuroscience.
• 11:12
  Speaker 1: Hard, unrelenting morning pain is what I should say like nothing really makes it feel better.
• 11:15
  Speaker 1: And then hard neuroscience, hard neurological signs, as in weakness and a certain pattern of muscles that are from that specific nerve root, and then also also sensory changes.
• 11:26
  Speaker 1: That's called a dermatome that innervates a skin area, region from a specific nerve root in your low back.
• 11:32
  Speaker 1: If you have hard neural signs in those myotoma and dermatoma patterns, unrelenting pain doesn't get better in the morning.
• 11:38
  Speaker 1: And then also pain with Valsalva, right, and you're younger, as in like below the age of 38, right, you're 35.
• 11:44
  Speaker 1: That's what I'm like.
• 11:45
  Speaker 1: Maybe this is actually a true disc.
• 11:46
  Speaker 1: Let's get it, let's refer out man, let's investigate another option, right, and of course with anybody.
• 11:51
  Speaker 1: And he did, and he had surgery and felt better.
• 11:52
  Speaker 1: I was like dude, perfect, high five, I'm happy, high five, right, we'd, sometimes we need that, um, but always not the case.
• 11:59
  Speaker 1: And of course, if we do conservative route first and it's not getting better, then guess what, we'll go get another opinion and do an MRI again, right, or just go that route.
• 12:08
  Speaker 1: We'll get an MRI and check it out and get a doctor, get a surgeon's opinion Totally Right.
• 12:12
  Speaker 1: But what if it works and you don't need surgery?
• 12:14
  Speaker 1: We just avoided it and you feel better, right?
• 12:17
  Speaker 1: That's where people get hung up on the imaging and they say but I still have the herniated disc.
• 12:22
  Speaker 1: That doesn't equal success or failure.
• 12:24
  Speaker 1: According to the research, there's plenty of people that have herniated discs present and they're totally fine.
• 12:28
  Speaker 1: It's not always the case of like success, failure.
• 12:32
  Speaker 1: Herniated discs, pain, structural abnormalities, dysfunction that's not always the case.
• 12:38
  Speaker 1: Just some food for thought, something to think about and something we chat with our patients about.
• 12:42
  Speaker 1: And there is definitely a different route you could go, if you want.
• 12:44
  Speaker 1: And if it's not getting better, um, then we'll definitely pursue another route and refer out.
• 12:52
  Speaker 1: Totally Right.
• 12:53
  Speaker 1: But what if it is getting better than we just avoid surgery?
• 12:54
  Speaker 1: Awesome, right, that's a win, right, anyway, so that's just a little food for thought.
• 12:58
  Speaker 1: Take that for what you want.
• 12:59
  Speaker 1: I'm always open to suggestions in the comments, questions, concerns, conflicting opinions, and always want to like to have a discussion conversation, so don't hesitate to reach out.