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Disc herniation in youngsters : what it is and how to prevent it

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Three out of ten people suffer from persistent troublesome pain in the lower back that sometimes radiates even as far as the lower limbs, a pain that lasts for a year or more rather than disappearing in two or three weeks as is normally the case. Commonly referred to as “sciatica” or “lumbosciatica”, it is due to a condition called lumber disc herniation, which is a common cause of pain, including low back pain, and can significantly impact the quality of life of those affected. Unfortunately, this problem is now also seen in youngsters, too: “Over the years, changes in kids’ lifestyles — they spend increasingly more time sitting down and less and less in movement — have gone hand in hand with a growing prevalence of certain diseases, including lumbar disc herniation,” explains physiotherapist Sara Rossi Raccagni.

Let’s examine more closely what we are talking about. When material from the nucleus pulposus of an intervertebral disc is pushed through a tear in the fibrous ring (annulus) that forms its wall, and therefore out of its natural location, the disc is described as herniated. The intervertebral discs are the cushions located between the vertebrae, which absorb the loads to which the spine is subjected in the course of the day. The discs most affected by this degenerative process are the ones located between the fourth and fifth lumbar vertebrae and between the fifth lumbar vertebrae and the sacrum.

What are the risk factors that may contribute to the occurrence of disc herniation?

A recent study (Risk factors for lumbar disc herniation in adolescents and young adults: A case-control study ) investigated risk factors for lumbar disc herniation in 208 patients aged up to 25 years.

Obesity, which corresponds to a BMI (body mass index) greater than 30, has been found to be closely associated with the risk of lumbar disc herniation, probably due to the greater load exerted on the structures of the spine.

Poor posture when seated and spending more than six hours a day seated have both been identified as risk factors for the onset of disc herniation: “So-called lazy postures (sitting slouched back in a chair with your pelvis slid forward, or sitting bent over with your head and upper body leaning forward) put the spine under extra stress and increase the likelihood of disc degeneration, especially when they are maintained for a long time” Rossi Raccagni goes on. “Prior low back traumas also seem to increase the risk of disc herniation, especially in athletes because of the greater stress exerted on the structures of the spine. This applies especially when training (and the initial warm-up in particular) is not done correctly”.

Finally, another risk factor to bear in mind is heredity, in other words, whether there are cases of herniated disc in the family that could be linked to genetic anomalies, i.e., mutations in genes coding for extracellular matrix components, inflammatory markers and protein metabolism.

With the exception of the latter risk factor, on which we cannot intervene, all the others can be controlled by adopting a healthy lifestyle, reducing as much as possible the time spent sitting down and doing regular exercise as appropriate for your physique.

To reduce the risk of accidental trauma, it is a good idea to warm up completely before starting any sport-specific training. This warm-up increases the elasticity of your muscles and your spinal range of motion in all directions. 

If you have a herniated disc, it is always advisable to consult doctors who specialise in the treatment of spinal disorders, as they can guide you step by step and also put you in the safe hands of expert physiotherapists. 

The first-choice treatment is the type termed “conservative”. Conservative treatment must always be multidisciplinary and can include the use of drugs (anti-inflammatory and neurotrophic drugs), postural education, cognitive-behavioural therapy, manual therapy and exercises” Rossi Raccagni concludes. “If the pain fails to improve with conservative therapy or neurological deficits arise (stenosis and/or marked sensory deficits), then the patient might be referred for surgery.

Disc herniation can also be treated using “minimally invasive” methods, which are considered to fall mid-way between conservative and surgical treatments. They include oxygen-ozone therapy and epidural injections.

Are bracing and exercises really still the only way to “solve” the problem?

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This is a question many parents ask us when scoliosis is diagnosed. Perhaps their child has a particularly tricky curve, or maybe they themselves can remember dealing with the same condition when they were young. It is the same question we were recently asked by the mother of a five-year-old girl who, at this tender age, already has to reckon with a challenging treatment, “trapped” in a brace.

 Unfortunately, despite huge strides made in the formulation of less invasive and more effective braces (such as the Sforzesco type that we at ISICO, have long used as a valid substitute for plaster casts), bracing and specific exercises remain the only conservative treatments available for scoliosis.  

No parent wants their child to suffer the same negative experiences that they themselves remember, and it is perfectly understandable to be concerned about the possibility of them living the “nightmares” we did, and to want to protect them as far as possible. On the other hand, if this is something you have gone through yourself, you will actually be ideally placed to really understand all the difficulties your child is likely to face, and to help them find the best way to cope. It is not being complaining to ask whether other options exist and whether your child really does have to wear that uncomfortable piece of plastic — these are, after all, questions that any parent would ask.

 So, to return to the question, are there any other effective and less difficult treatments? Unfortunately, as explained in a recent study, manipulation and osteopathy, like all manual treatments, have not yet been shown to be effective (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9833903/).

Given the questions we so often get asked, we feel it is essential to properly explain the reason for certain aspects of the treatment, such as the need to ensure that brace-off hours are consecutive, the importance of performing specific exercises, and the duration and dosing of the treatment.

When deciding how long the treatment will last and how aggressive it needs to be in terms of the dose (i.e., number of brace-on hours per day), the factor we consider is the potential risk of the condition worsening. This risk is assessed based on the extent of the scoliotic curve and how much growing the patient still has to do (residual growth). Scoliosis worsens with growth, therefore the earlier it arises, the more likely it is to get worse, especially during growth spurts, when the youngster gains height rapidly (these usually happen at 6/7 years of age and in puberty).

Based on this information, the treatment can be adjusted, reducing or increasing the dosage according to the period of risk.

It also follows that the earlier scoliosis arises, the longer the treatment will need to be, given that bone growth has to be complete to reach a stable situation. Then there is the question of the “brace-on” hours. It has been demonstrated that after putting on a brace, it takes at least two hours for the spine to achieve the desired correction. 
This means that, when the brace is repeatedly taken off and put back on, we have to consider, and count, not only the brace-off hours, but also the hours needed for the spine to return to its correct position inside the brace. In the same way, every time the brace is removed the back tends to spring back to its starting condition (rather like a spring that has been pulled and then reverts to its original shape).

Then, the more frequently the brace is taken off to give the patient a break, the less effective the treatment will be compared with wearing it for the same number of hours but with fewer and longer breaks. For this reason, it is essential to try and establish and maintain a regular brace-wearing schedule.

We know that bracing treatment is very challenging and also that managing the brace-off hours can be difficult, especially during the summer. For this reason, we advise families, as far as possible, to choose somewhere cooler for their holidays, and also to talk to their specialist to see whether, on some days during the summer, the brace-on hours can be reduced or the brace-off time can be split into two blocks. Obviously, these decisions have to be taken on a case-by-case basis.

As for the specific exercises for scoliosis, these are designed to help support the back when the brace is not being worn, and also to prevent loss of muscle tone (otherwise an inevitable consequence of bracing). In the case of very young children (like the little girl whose mother prompted us to write this post), we recommend lots of sport to keep the muscles in shape, because children aged 4 to 6 years often don’t yet have the concentration necessary to be able to cope with exercise sessions.

Finally, in answer to the question, yes, at present, bracing and exercises are the only conservative therapy options that have been shown to work. This kind of treatment is certainly difficult and demanding, but we have to remember that it aims to help our children reach adulthood with healthy backs, and fortunately, we do at least have these “instruments” to offer them. 

Different specialists, different prescriptions: how should we choose?

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Most parents of a child with scoliosis embark on a similar journey: once they have received the initial diagnosis, they start consulting other specialists, seeking second or third opinions that might provide them with the confirmation and reassurance they need, and/or simply answers to further questions and doubts that have cropped up in the meantime. 

Often, though, parents who do this find themselves left with more questions than answers. This is because different specialists, faced with the same scoliosis case, can make different diagnoses and prescribe different courses of treatment.

Why is this? There may be different reasons. Before going any further, though, it is important to remember that only a specialist with specific training in vertebral pathologies can treat scoliosis. Once a timely and correct diagnosis has been made, it is necessary to decide how to treat the condition. 

The SOSORT guidelines on conservative treatment of scoliosis are an important resource in this regard. Taking into account the best current scientific evidence, as well as the extent of the curves and the degree of bone maturation, they provide suggestions on the most effective treatment. 

What the guidelines offer is not a single, specific course of treatment, but rather a series of options, ranging from the most conservative to the most aggressive, that could conceivably be prescribed in a given patient. 

However, science alone cannot meet all the needs of a long and complex course of treatment of the kind required in scoliosis. The evidence-based medicine approach brings together and combines scientific knowledge, the expertise and experience of the specialist, and the values and desires of the patient, and therefore makes it possible to formulate the most appropriate prescription for the individual case. 

Bearing all this in mind, then, it may well be that one doctor, considering the data collected during the examination and the discussion with the patient and the patient’s family, decides to prescribe a brace where another doctor might instead recommend only specific physiotherapy or even a wait-and-see approach, which consists of monitoring the situation for a few months to see how the scoliosis evolves.
These are very different prescriptions, but they are all valid. The patient will in any case be monitored following the prescription in order to make sure that the type of treatment, and the dose, are correct.
In this way, it is also possible to make any changes needed to avoid under-treatment (insufficient to contain the progression of the disease) or over-treatment (too taxing for the patient).

The big question remains: how do we parents go about choosing? There’s no easy answer. Given that our children will need to be on this therapeutic journey until they have finished growing, the important thing is to find someone we feel we can trust. In other words, we need to choose the specialist — and it must be someone with expertise in the conservative treatment of scoliosis — who we, and our child, felt to be the most reassuring and empathetic.

Once we have made our choice, we need to place our child’s care in the doctor’s hands. It is important to follow the instructions we are given, and not to change anything without the doctor’s agreement, as to do so could undermine the success of the treatment.