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Symptoms of this syndrome indicate nerve compression on both motor and sensory fibers of the spinal cord and include low- back or lower extremity pain; bowel, bladder, or sexual dysfunction; or other symptoms of pelvic floor sensory or motor impairment. If your client is exhibiting any of these symptoms, especially if they are felt bilaterally, they should immediately consult a physician. One of the things we have learned from recent MRI studies is that disk pathology happens in a high percentage of the population who have no symptoms whatsoever. The table on page 93 shows a comparison chart of the frequency with which various disk pathologies exist in healthy individuals with no symptoms. That means just because somebody has a herniated disk, even if they have corresponding pain, we can't determine that their pain is necessarily coming from the disk problem. Some studies have also shown that people's pain perceptions can possibly increase after being shown medical imaging (such as MRI or X-ray) that indicates apparent damage or dysfunction. The table shows various age brackets and the percentage of people in that bracket with imaging who show disk pathology (but not necessarily any pain or symptoms). 3 ASSESSMENT AND CONCEPTS Identifying disk pathology with physical examination is challenging. Various physical examination methods, such as the straight leg raise test or slump test, are used in conjunction with clinical signs to suggest the likelihood of disk pathology. However, high-tech diagnostic studies, such as MRI, are needed to confirm the presence or severity of disk pathology. What is important for massage therapists to consider is what role our treatments can play in addressing various disk pathologies. Disk Degeneration The next category of disk pathology is called degeneration. Degeneration results from a variety of sources that may include multiple annular tears, loss of water content in the disk, disintegration of the annulus, and vertebral osteophytes. Degeneration usually involves a loss of disk thickness, which then causes spinal stenosis. Spinal stenosis involves a narrowing of the intervertebral foramen caused by the vertebrae coming closer together. The intervertebral foramen is a small opening where nerve roots exit the spine. When the foramen is reduced, there is a greater likelihood of nerve root compression. Disk Herniation The third category of disk pathology is called herniation. Disk herniation is the pathology most associated with low-back or cervical pain or pain that extends down the length of the extremity from affected nerve roots. What is sometimes confusing about disk herniations are the various terms used to describe different types of disk pathology. The herniation is defined as a "localized displacement of disk material beyond the limits of the intervertebral disk space." 2 There are several types of disk herniations, and the easiest way to understand them is with a diagram that describes the percentage of disk displacement (Image 5). If there is a displacement that affects more than 25 percent of the disk, it is considered a broad- based displacement and generally referred to as a disk bulge. Most disk bulges are the result of annular tears. If the displacement involves 25 percent or less of the disk, it is generally referred to as a focal herniation. Focal herniations are then broken down into two separate categories: • Protrusion: base of the herniation is wider than the tip • Extrusion: tip of the herniation is wider than the base In some cases, disk material from extrusion will continue to separate from the main body of the disk. This is called a sequestration. When material in the nucleus pushes out the edge of the annulus and causes a disk herniation, the primary concern is that disk material can press on adjacent structures, particularly nerve roots. Herniations most commonly occur at the posterior lateral edge of the disk, as there is no restraint by adjacent tissues in this direction. Unfortunately, this is where the nerve roots are located. In some cases, the disk will push straight posteriorly against the posterior longitudinal ligament. When it does, there is a good chance it will press directly on the spinal cord. This occurs most frequently in the lumbar region and can be a dangerous situation called cauda equina syndrome. 5 Percentage of disk displacement in defining herniations. Mediclip image copyright (1998) Williams & Wilkins. All rights reserved. Protrusion Extrusion Sequestration Ta k e 5 a n d t r y A B M P F i v e - M i n u t e M u s c l e s a t w w w. a b m p . c o m / f i v e - m i n u t e - m u s c l e s . 91