Your Discs Are Bulging—Does it Matter?

Have you been told that you have bulging, degenerated discs in your spine? If so, you are not alone. Millions of Americans undergo X-rays, CT scans, and MRI scans of their backs and necks each year and receive the same news. As a result, multiple millions of dollars are spent on medications, physical therapies, surgical procedures, and spinal manipulations in an effort to treat back pain. The people undergoing all this diagnosis and treatment might imagine that other, luckier people have normal spinal discs, but they might be surprised to learn that bulging discs are so common that they may be considered a normal part of aging. Most often, they cause no symptoms or problems, and it pays to be cautious about embarking on courses of investigation and treatment based simply on these “degenerative changes.” But it also pays to know when and why discs do cause trouble.

What and where are spinal discs?

The spine is a column of thick, circular bones—also called vertebral bodies—that in terms of anatomy is divided into three major sections: the cervical (neck) spine, thoracic (mid-back) spine, and lumbar (lower back) spine. The vertebral bodies have flat tops and bottoms, and they sit atop one another, separated by discs that cushion the spine and allow for the compression, rotation, and bending of the entire spinal column. The arches of bone on the back sides of each of the vertebral bodies line up with each other to form a bony tunnel, which surrounds the spinal cord and the nerves that connect it to the body. Pairs of these nerves exit from the sides of this canal below each vertebral body.

Spinal discs are a lot like flattened cream-filled doughnuts, with a soft center called the nucleus pulposus and a tougher perimeter called the annulus. Each annulus is attached to the ligaments that run the length of the spine and hold it together. Every day, gravity squeezes so much water out of each disc that an average adult shrinks by more than one-half inch between morning and night. As a disc loses water and flattens, it may protrude beyond the edges of the vertebral bodies located above and below it. Under these conditions, the ligaments bounding the disc tend to bow outward to accommodate the flattening, and the result is the classic “bulging” discs often seen on back scans. Is such bulging a cause of pain?

When bulging becomes cracking and herniation

Judging by the number of people who have bulging discs and no pain, the answer to this question is, not very often. But discs can cause pain if they are damaged. Cracks can develop in the back part of the annulus, especially in the lower neck and lower back, and are sometimes caused by sudden movement or excessive loading of the neck or back or sometimes with no readily identifiable cause. Risk factors for the development of cracks include age, smoking, and heavy weight lifting. When cracks form in the annulus, nerve fibers send out distress signals which feel like deep back pain that sometimes radiates down the legs. Symptoms usually improve over a period of six to eight weeks, but if the tear is extensive enough, it may open a path for part of the soft nucleus pulposus of the disc to work its way through, becoming a so-called herniated or “slipped” disc.

Location determines  symptoms

Extruded far enough, a herniated disc bulges straight backward into the bony tunnel that houses the spinal cord or off to either side, where it squeezes into the narrow canal that should hold only a spinal nerve root passing out to the body. Depending on the location and the extent of the disc herniation, pain in the back or neck might be accompanied by a set of neurological symptoms including numbness, tingling, and a sense of weakness in an arm or a leg. Symptoms may improve over time with no treatment or with relatively modest treatments, like physical therapy or cortisone injections, as the disc shrinks. But there is potential for the worsening of symptoms, so careful physical evaluation and follow-up are important.

More than 95 percent of disc problems occur in the lumbar spine. Here, as in the neck, discs tend to slip off to the side, compressing single nerves and causing pain to run down a leg or arm or weakness in corresponding muscles. Definite loss of strength in a muscle group controlled by the nerve under pressure most often calls for surgery to decompress the nerve. Sometimes scans indicate that a fragment of disc has broken off and lodged itself under a nerve. Unlike nonfragmented disc herniations, which may gradually shrink and relieve symptoms, symptoms caused by fragmented discs tend to be persistent unless the fragment is removed.

Disc herniation in the upper spine

When discs slip straight back into the central spinal canal, symptoms can range from none to neurological deficits that require immediate decompression surgery. Serious central disc herniations are uncommon in the neck and quite rare in the thoracic spine but in both locations may cause symptoms from the spinal cord itself that include pain, balance problems, weakness in the legs, and an inability to control the bladder.

Disc herniation in the lumbar spine

In the lumbar spine, because the spinal cord does not reach down this far, central disc herniations put pressure on the so-called cauda equine, or “horse’s tail” of nerves that travel down the spinal canal from the spinal cord to their exit points at different lumbar levels. Symptoms here often consist of a confusing array of pain, numbness around the groin and legs in a pattern that traces an area where a saddle would make contact with the body, leg weakness, fecal incontinence, and trouble initiating urination. This combination of symptoms requires immediate surgical decompression.

Surgery or not?

While surgery for severe symptoms is an easy decision and while many disc removals are done with microsurgical techniques and small incisions and are less invasive than in the past, the decision to try to improve back pain alone by operating on a bulging disc is not as easy. To improve the likelihood of good results, studies like disc injections are sometimes done. The dye used helps visualize the disc, and, if the injection reproduces the patient’s pain, confidence that the disc is the source of the back pain increases. Injections can be helpful in determining which of several bulging discs might be the source of pain.

Caution in the decision

Disc removal for pain alone or for pain combined with sensory symptoms that come and go should be approached with caution. First, every attempt should be made to improve the strength of the muscles that support and move the spine, to improve overall posture, and to lose excess weight that the spine is asked to support. Back and neck pain arise from many different structures—muscles, ligaments, tendons, bones, and nerves—and can improve dramatically with improved strength, flexibility, and posture—bulging discs or not.

 

Torn Aortas: Saving Life Depends on Recognizing Symptoms

“There is no disease more conducive to clinical humility than aneurysm of the aorta.”   William Osler, 1849-1919

    John Ritter, star of television’s Three’s Company, died unexpectedly at age fifty-four from aortic dissection, a catastrophic event which starts as a small tear in the lining of the aorta, the largest blood vessel in the body. His tear, like most aortic dissections, occurred in the part of the aorta that exits the heart and ascends toward the head, but dissections can anywhere along the course of the aorta as it turns and then descends along the back wall of the chest and abdomen. Actor Alan Thicke’s recent death has also been attributed to an aortic tear. In neither case was the cause of death confirmed by autopsy, presumably because diagnosis was made clinically and by imaging studies once the men reached medical care. Diagnosis in both cases came too late for their lives to be saved. The first step in saving the life of someone with an aortic dissection is recognition of the symptoms. As Osler accurately stated, this is not necessarily easy. 

Upper Aortic Symptoms 
Symptoms of aortic tears vary according to the part of the aorta involved. In the upper aorta, as in Ritter’s case, the tear appears without warning. The first symptoms, such as severe chest pain, confusion, dizziness, nausea and vomiting, come from blood tunneling its way into the tear and under the aortic lining, separating it from the thick outer wall of the blood vessel. Heartbeat by heartbeat, the tunnel enlarges and a growing clot of blood extends around the inner circumference of the aorta and along its length, stretching from the ascending part of the thoracic aorta into the curved aortic arch branches where large arteries branch off and carry blood to the head and arms. 

The differences between dissection and heart attack symptoms

    Sadly, like John Ritter, almost 40 percent of people with upper aortic dissection who get to medical attention are not diagnosed in time for doctors to attempt surgical repair. Within forty-eight hours, half of them are dead. Diagnosis depends on recognition of subtle and qualitative characteristics of symptoms that differ from similar heart attack symptoms. Chest pain is severe from the beginning and sometimes described as ripping or tearing. Its most distinctive quality is sudden onset of maximally severe pain . Often people report a sense of impending doom. The pain may radiate up the neck or into the back, as it can in a heart attack. As the dissection progresses, clotting blood can block the openings to the aortic arch branches and even work its way backwards to damage the coronary arteries that nourish the heart. The aortic valve may be damaged and begin to leak. 

Symptoms From the Descending Aorta

     While the involvement of so many other structures in an upper aortic dissection can produce a host of symptoms that manifest themselves in the heart, the brain, the neck, the face, and the extremities, sometimes confusing physicians, descending aortic symptoms are more straightforward. Pain from dissection in the descending thoracic aorta bores through to the back. In the abdominal aortic segment dissection pain may be felt in the flank, lower back, or groin. Because the descending aorta is more tightly bound to surrounding structures, tears may be more confined and symptoms less severe. 

Dissections and Aneurysms

   Sometimes a dissection begins in an aortic wall already weakened enough to have ballooned out into an aneurysm, which is a distended spot in an artery wall. Ninety-five percent of aortic aneurysms are located in the abdominal aorta, and aortic dissections in the abdomen are often triggered by the prior development of an aneurysm. A tear in the wall of an aneurysm can cause the aorta to rupture completely causing internal bleeding, with mortality rates between 75 percent and 90 percent of aortic aneurysms Fortunately, aneurysms are often found incidentally on imaging tests for other problems, or as part of an investigation of vague abdominal or back pain or of a pulsating sensation in the lower abdomen allowing time for surgical repair of the damaged artery before rupture occurs. 

Who’s at Risk
    Most upper aortic dissections occur in people between the ages of forty and seventy, with men affected three times as often as women. In otherwise healthy and relatively young people like John Ritter, the tear begins because the aortic wall is weakened by genetic processes that are often poorly understood. Pregnancy and cocaine use are also risk factors below age 40. In older people and in smokers high blood pressure, atherosclerosis are responsible for the breakdown in the aortic lining, but even in these patients, dissections tend to run in families. 

     While smoking, hypertension, and atherosclerosis are risk factors in all types and locations of aortic disease, the abdominal aorta is particualry susceptible to their degenerative effects. Abdominal aortic disease is far more common than the forms of aortic disease that affect younger people and most aneurysms of the abdominal aorta reflect age-related (over age sixty) vascular degeneration. An estimated 5 percent of men over age sixty-five have some degree of degenerative abdominal aortic dilatation. 

The importance of family history
Assessment of a patient’s family history is very important in diagnosing aortic diseases like aortic dissection because genes control the proteins that make up the connective tissue of the thick aortic wall, and there can be a hereditary predisposition to dissection and aneurysm formation, particularly in younger people like John Ritter. One relatively common condition (1 in 5000 people), which can affect the connective tissue and lead to aortic dissection, is Marfan’s syndrome. The Olympic volleyball star Flo Hyman had Marfan’s syndrome, which accounted for her six feet five stature and long arms and fingers. She died at age thirty-two of aortic dissection. Dissections can also occur in people with congenital heart abnormalities, particularly those that affect the aortic valve.  

Treatment
Surgical repair of aortic aneurysms and dissections is a serious and complicated undertaking. Incidentally discovered abdominal aneurysms and aneurysms found by screening programs should be followed carefully with ultrasound or computerized tomography scans because the risk of rupture is correlated with the size of an aneurysm. Surgical repair is far less dangerous when done before dissection or rupture but carries risk enough to warrant waiting if the aneurysm is less than five centimeters in diameter. 

    Once a dissection has begun, the outcome of surgical repair rests heavily on the condition of the patient going into surgery, on the experience of the surgical team and hospital involved, and on the complexity of the procedure required. In recent years, radiologists and cardiologists have developed procedures to repair the inside of the aorta by deploying stents and grafts via catheters inserted though the arms or legs and guided by x-ray. Initially, these procedures were only used on patients who were too frail or sick to undergo the rigors of open surgery. Increasingly, though, these less invasive procedures are gaining favor and are even being used to repair dissections of the descending thoracic aorta, which have traditionally been treated by careful control of blood pressure. More research will have to be done to assess the long-term outcome of stent and graft treatments. 

Not even recent technological advances would have helped John Ritter, however, because the proper diagnosis was not made prior to his death. His family has since set up an educational foundation called the John Ritter Foundation for Aortic Health (http://johnritterfoundation.org/your-aortic-health/) with the goal of increasing knowledge and awareness about a disease which is still a very humbling clinical problem for the medical professio

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