Intervertebral disc

The intervertebral disc is a cartilaginous tissue that is located between the vertebrae and serves for amortization during movements and loads on the spine itself. 

There are 23 intervertebral discs in the human spine.:

  • 6 in the cervical spine
  • 12 in the thoracic spine
  • 5 in the lumbar spine 
The intervertebral disc consists of 3 parts: 
  • Central gelatinous nucleus (nucleus pulposus) – consists of water (66 to 86%), collagen and proteoglycans and sits in the middle of the intervertebral disc and it is responsible for most of the flexibility of the spine
  • Peripheral hard ring (annulus fibrosus) - consists of lamellae or concentric layers of collagen fibers and serves as a protection for the inner core and helps to absorb shock to the spine during movement
  • Two vertebral end plates - the upper and lower end plates (0.6 – 1 mm thick) cover the upper and lower part of the disk, allow diffusion and provide the main source of nutrition for the disk itself 
Herniated disc

Disc protrusion (herniated disc)

There are different types of degenerative disc changes, but one of the most common is intervertebral disc hernia. 

A hernia occurs when the content of the gelatinous nucleus (nucleus pulposus) protrudes through the lamellae of the hard ring (anulus fibrosis) leading to a displacement of the disc outside the intervertebral space. 

Due to the physiological shape of the intervertebral disc, protrusion usually occurs posterior – lateral (back and out of the spine) and thus can protrude into the spinal canal and create problems for the patient. 

The whole process of disc protrusion results in a decrease in stability and an increase in the load on the segment of the spine where the protrusion occurred. 

Stages of disc herniation

There are 4 stages of herniated disc: 

  1. Bulging disc - often does not show any symptoms because it is not large enough to put pressure on nearby nerves and the spinal cord 
  2. Protrusion of the disk – at this stage you can begin to feel pain in the area where the prolapse of the disk is located and where the compression is formed
  3. Disk extrusion - the nucleus penetrates the disk wall and exits to the surface
  4. Disk sequestration - the nucleus begins to leak out of the disk
The first 2 stages are stages of incomplete disc herniation in which the gelatinous core has not yet leaked through the hard ring. Instead, the core causes the disc to protrude and exerts pressure on the outer tissues.

During the 3. and 4. stage the nucleus penetrates the disc wall and more serious symptoms develop in the patient. At this stage, symptoms such as numbness, weakness, pain and tingling in the lower back and along the legs may occur. 

Stages of disc herniation
Exercises for disc hernia

Treatment of herniated disc

Treatment of disc herniation can be conservative or non-operative and operative or surgical. 

Conservative treatment of intervertebral disc hernia is similar to tendinopathy and occurs in 3 stages: 

  1. Initial inflammatory phase - At this stage it is necessary to protect the discs from further damage and visit a medical doctor or physiotherapist as soon as possible to refer you for further tests and give you instructions so that there is no greater damage to the disk than it was before. Also at this stage, anti-inflammatory drugs and creams, and passive modalities such as dry needling, cupping,massage and similar modalities that will not cause greater damage to the disk but will relieve the pain itself. 
  2. Repair phase - After the inflammatory phase has ended the repair phase starts. We introduce first static and then dynamic exercises and other necessary therapy modalities to stimulate further disk regeneration. 
  3. Remodeling phase - In the last phase of rehabilitation, we progress into dynamic rotational movements in order to enhance the regeneration of the nucleus pulposus and anulus fibrosus. Also at this stage we introduce eccentric exercises and progressive load on the spine itself. 
Surgery is performed exclusively in cases where the patient does not control urine and stool and cannot move freely. More precisely when the magnetic resonance imaging shows that the disk is pressing the vital structures and there is no other solution than surgery. 
Bsc. PT. Toni Marić

Bsc. PT. Toni Marić

Toni is bacc. physical therapist and the owner of the Ad Sacrum clinic who has been treating top athletes for years and also teaches at the Dry needling courses for physiotherapists.

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