A Special Guideline of What is PLID Disease. PLID stands for Prolapsed Lumbar Intervertebral Disc, commonly referred to as a slipped or herniated disc. It occurs when the Inner gel-like material of a lumbar intervertebral disc protrudes through a tear in its outer ring, potentially compressing nearby nerves. This can lead to symptoms like lower back pain, sciatica (radiating pain down the legs), numbness, tingling, and in severe cases, loss of bladder or bowel control.
The most common locations for PLID are between the L4-L5 and L5-S1 vertebrae. Causes of PLID can include trauma, repetitive strain, poor posture, or aging-related degeneration of the discs. Risk factors such as obesity, heavy lifting, or prolonged sitting can increase the likelihood of developing this condition.
Anatomy of Lumber Spine
The lumbar spine is a critical region of the vertebral column, consisting of five vertebrae (L1-L5) located in the lower back. These vertebrae support much of the upper body’s weight and facilitate a wide range of movements, including bending, twisting, and lifting.
Vertebrae: The lumbar vertebrae are the largest vertebrae in the spine, reflecting their role in bearing the body’s weight. Each vertebra consists of a vertebral body, which is the thick, weight-bearing section at the front, and a vertebral arch at the back that forms the spinal canal, housing and protecting the spinal cord.
Intervertebral Discs: Between each lumbar vertebra is an intervertebral disc, which acts as a cushion and shock absorber, allowing the spine to bear weight and manage the forces exerted during movement. These discs consist of two primary components: the tough, fibrous outer layer called the annulus fibrosus, and the softer, gel-like center known as the nucleus pulposus. The annulus fibrosus provides structural integrity, while the nucleus pulposus helps distribute compressive forces across the spine.
Facet Joints: These are small, paired joints at the back of each vertebra that help stabilize the spine and allow for controlled movements like bending and twisting. Each lumbar vertebra has two sets of facet joints: superior and inferior articular facets, which link the vertebrae together. These joints are crucial for spinal flexibility and alignment.
A Special Guideline of What is PLID Disease
Spinal Cord and Nerve Roots: The spinal cord runs through the vertebral canal of the lumbar spine, but it terminates at around the L1-L2 level, transitioning into a bundle of nerve roots known as the cauda equina. These nerve roots extend downward, exiting the spine at different points along the lower back to transmit signals between the brain and the lower body. The cauda equina is responsible for motor and sensory innervation of the legs and bladder, and compression in this area can lead to severe neurological deficits.
Muscles and Ligaments: The muscles and ligaments surrounding the lumbar spine play an essential role in maintaining posture, enabling movement, and providing spinal stability. The primary muscles involved are the erector spinae, which extend along both sides of the spine, and the multifidus, a deep muscle responsible for small, stabilizing movements between the vertebrae.
Ligaments such as the anterior and posterior longitudinal ligaments, which run along the front and back of the vertebrae respectively, prevent excessive spinal movements, protecting it from injury. Additional ligaments, including the ligamentum flavum and the supraspinous and interspinous ligaments, provide further stability to the spine and limit its range of motion.
Curvature: The lumbar spine has a natural inward curve known as lordosis, which helps balance the body and distribute mechanical stress during movement and standing. This curvature enhances the spine’s ability to absorb shock and protect the vertebrae and intervertebral discs from excessive pressure. However, abnormalities in the curvature, such as hyper-lordosis (excessive inward curvature) or hypo-lordosis (reduced curvature), can result in back pain and instability.
Causes of PLID
Prolapsed Lumbar Intervertebral Disc (PLID), also known as a herniated disc, occurs when the soft inner core of the disc (nucleus pulposus) protrudes through a tear in the tough outer ring (annulus fibrosus). Several factors contribute to the development of PLID:
Degeneration and Aging: The most common cause of PLID is disc degeneration due to aging. Over time, intervertebral discs lose water content and elasticity, a process known as disc degeneration. This makes the discs more prone to damage and less able to absorb shocks. The nucleus pulposus dehydrates, reducing its cushioning capacity, while the annulus fibrosus becomes more vulnerable to small tears, leading to disc prolapse. As the disc material presses against surrounding nerves, it can result in symptoms such as back pain and sciatica.
Trauma or Injury: PLID may also develop as a result of sudden trauma or injury. High-impact incidents, such as car accidents, falls, or sports-related injuries, can cause excessive pressure on the spine, leading to a tear in the annulus fibrosus and subsequent herniation of the nucleus pulposus. When the disc material presses against nerve roots, it can cause neurological symptoms, including numbness and radiating pain down the legs.
Poor Posture and Spinal Alignment: Poor posture is a significant contributor to PLID. Maintaining improper posture for extended periods, such as slouching while sitting or standing, increases the pressure on the lumbar intervertebral discs. This additional strain weakens the outer layer of the discs, particularly in the lower back, making them more susceptible to tears and herniation. Prolonged poor posture can accelerate the wear and tear on the lumbar spine, raising the risk of PLID.
Excess Weight: Excessive body weight increases the mechanical load on the lumbar discs. The added pressure exacerbates the wear and tear on the disc structures, accelerating their degeneration. Obesity is a well-documented risk factor for PLID, as it significantly increases the risk of disc herniation due to the excessive force on the spine. Over time, the strain on the annulus fibrosus can lead to tears and prolapse.
Genetics: Genetic predisposition plays a role in disc degeneration and herniation. Individuals with a family history of disc-related issues are more likely to experience early-onset disc degeneration, which can increase the risk of herniation. Genetic factors can affect the composition and resilience of the disc’s collagen fibers, making them more prone to structural weakening over time.
Repetitive Motion: Jobs or activities that involve repetitive bending, twisting, or lifting can lead to PLID. These motions place continuous stress on the lumbar discs, eventually causing small tears in the annulus fibrosus. Repetitive strain on the spine accelerates disc degeneration, increasing the likelihood of disc prolapse (1). Occupations that require heavy lifting or long periods of sitting are particularly associated with a higher risk of PLID.
Other causes of PLID
Lifestyle-related causes of Prolapsed Lumbar Intervertebral Disc (PLID) include several factors that increase the risk of disc degeneration and prolapse due to daily habits and behaviors. These causes include:
Sedentary Lifestyle: Lack of physical activity is a major risk factor for PLID. Prolonged sitting, especially with poor posture, places undue pressure on the lumbar discs, disrupting the natural curves of the spine. This continuous strain weakens the discs, making them more prone to degeneration and prolapse. A sedentary lifestyle also leads to weakened core and back muscles, which reduces spinal support and increases the risk of disc herniation.
Heavy Lifting and Improper Body Mechanics: Improper lifting techniques, particularly bending from the waist instead of the knees, can put excessive strain on the lumbar spine, leading to disc damage over time. Repeated heavy lifting, especially without proper body mechanics, increases the risk of herniation. Proper lifting techniques, such as lifting with the legs and keeping the load close to the body, can reduce this risk.
Lack of Exercise: Regular physical activity is essential for maintaining muscle strength and flexibility, which are crucial for spinal stability. A lack of exercise weakens the muscles that support the spine, particularly in the core and lower back. As these muscles weaken, the spine absorbs more stress, increasing the risk of disc degeneration and prolapse.
Obesity and Poor Diet: Excessive body weight significantly contributes to PLID. Obesity places additional mechanical stress on the lumbar spine, accelerating disc degeneration. Moreover, an unhealthy diet lacking essential nutrients can affect the overall health of the spine, leading to weakened disc structures.
Smoking: Smoking has been shown to impair blood flow to the spinal discs, reducing the delivery of essential nutrients and oxygen. This compromised circulation weakens the discs and accelerates their degeneration. Smokers are at a higher risk of developing disc herniation due to the increased rate of disc degeneration.
PLID symptoms and diagnosis
Prolapsed Lumbar Intervertebral Disc (PLID), commonly known as a herniated disc, manifests with a range of symptoms, primarily depending on the severity and location of the disc herniation. These symptoms can affect the lower back, legs, and sometimes bowel and bladder function.
Symptoms
Lower Back Pain: One of the earliest and most common symptoms of PLID is lower back pain. This pain occurs when the prolapsed disc compresses surrounding structures, particularly the nerve roots in the lumbar spine. The intensity of pain can vary, from mild discomfort to severe, debilitating pain. Pain is often exacerbated by activities like bending, lifting, or prolonged sitting, which increase pressure on the herniated disc. Additionally, movements such as coughing or sneezing may intensify the pain due to increased intradiscal pressure.
Sciatica: Sciatica is a hallmark symptom of PLID. It results from the compression of the sciatic nerve, which runs from the lower back, through the buttocks, and down the legs. This compression causes sharp, burning, or shooting pain that radiates from the lower back to the legs and feet. Along with pain, patients often experience numbness, tingling, or muscle weakness in the affected leg.
Numbness and Tingling: Numbness and tingling are frequent symptoms of nerve root compression caused by PLID. These abnormal sensations are typically felt in the legs, feet, or toes and are often described as a pins and needles sensation. Nerve compression from the herniated disc impairs normal nerve function, leading to these sensory disturbances.
Muscle Weakness: PLID can also result in muscle weakness, particularly in the legs or feet. When nerve roots that control specific muscle groups are compressed, it disrupts the communication between the brain and muscles, causing weakness. This can affect mobility, making it difficult for individuals to walk, stand, or lift objects. In severe cases, muscle weakness can impair the ability to perform basic activities like climbing stairs or rising from a seated position.
Loss of Reflexes: Loss or reduction of reflexes is another significant symptom of PLID. The compression of nerve roots can interfere with the normal reflex arcs, such as the patellar (knee-jerk) and Achilles reflexes, which can be diminished or absent in affected individuals. These reflex changes are important indicators during a neurological exam and help identify the level of nerve involvement.
Loss of Bladder or Bowel Control: Rare and severe cases of PLID can cause cauda equina syndrome, a medical emergency whereby a big herniated disc compresses the bundle of nerve roots at the lower end of the spinal cord.
(cauda equina). This can cause loss of bladder or bowel control, along with severe lower back pain, leg weakness, and numbness in the genital or perineal region. Immediate medical attention is required to prevent permanent nerve damage.
Diagnosis
Diagnosing PLID requires a comprehensive approach involving both clinical examination and diagnostic imaging techniques.
Physical Examination
During the physical examination for diagnosing Prolapsed Lumbar Intervertebral Disc (PLID), a healthcare provider assesses the patient’s symptoms and performs various tests to evaluate nerve function, muscle strength, and mobility. The examination typically includes:
- Palpation and Visual Inspection: The physician examines the lower back for signs of muscle spasms, tenderness, or misalignment that could indicate a herniated disc.
- Range of Motion Tests: The patient is asked to bend, twist, and flex their spine to identify pain during specific movements. Limited mobility or increased pain during these movements can be indicative of PLID (2).
- Reflex Testing: Reflexes, such as the patellar and Achilles reflexes, are tested to detect reduced or absent responses, which may indicate nerve root compression.
- Straight Leg Raise (SLR) Test: The SLR test involves raising the patient’s leg while they are lying down. If this maneuver elicits pain radiating down the leg, it suggests irritation of the sciatic nerve, often due to a prolapsed disc (2).
- Neurological Assessment: The physician evaluates muscle strength and sensory function in the legs and feet. Weakness, numbness, or tingling in specific areas helps identify which nerve roots are affected by the disc herniation.
Imaging
- X-rays: While X-rays do not show the disc itself, they are often used to rule out other causes of back pain, such as fractures or tumors (8).
- MRI (Magnetic Resonance Imaging): MRI is the gold standard for diagnosing PLID, as it provides detailed images of the intervertebral discs, nerve roots, and surrounding structures. It allows for precise localization of the disc prolapse and assessment of its severity.
- CT scan: Although less effective than MRI in visualizing soft tissues like discs, CT scans can be used when MRI is unavailable. CT myelography, a specialized form of CT scan, can be helpful in identifying nerve compression (8).
- Electromyography (EMG): EMG tests the electrical activity of muscles and nerves to determine whether there is nerve damage or compression. It is used to assess the extent of nerve involvement in PLID.
PLID treatment
The treatment of Prolapsed Lumbar Intervertebral Disc (PLID) involves a combination of conservative therapies and, in more severe cases, surgical intervention, depending on the severity of the symptoms and the extent of the disc prolapse. Here’s an overview of the common treatment options:
Conservative Treatment Options
Rest and Activity Modification
Patients are typically advised to avoid activities that worsen their symptoms, such as heavy lifting or prolonged sitting. While short-term bed rest may be recommended, extended inactivity is generally discouraged, as it can lead to muscle weakening and exacerbate the condition.
Pain Management
- Non-steroidal anti-inflammatory Drugs (NSAIDs), including ibuprofen, are frequently used to diminish inflammation and relieve pain.
- Muscle relaxants and analgesics are used to manage muscle spasms and discomfort, providing temporary relief.
- Corticosteroid Injections (epidural steroid injections) may be administered to reduce inflammation around the affected nerve root and relieve pain (4).
Physical Therapy
Exercise Programs: Physical therapy for PLID often focuses on strengthening the core muscles, which help stabilize the spine and relieve pressure on the intervertebral discs. Exercises such as abdominal bracing, bridges, and planks are commonly used to enhance lumbar spine stability.
Stretching and Strengthening Exercises: Stretching exercises target the muscles surrounding the spine, including the hamstrings and hip flexors, to improve flexibility and reduce stiffness. Movements like pelvic tilts and hamstring stretches are beneficial in reducing pressure on the prolapsed disc and improving mobility.
Manual Therapy: Manual therapy techniques such as spinal mobilization and manipulation are essential in the management of PLID. These hands-on techniques help improve spinal alignment, reduce nerve compression, and restore normal motion to the affected area (3). Spinal manipulation, in particular, can provide immediate relief for some patients by realigning the vertebrae.
Heat/Ice Therapy: Alternating between hot and cold packs can be effective in reducing inflammation and providing temporary pain relief.
Lifestyle Changes
Weight management, smoking cessation, and proper body mechanics during daily activities are critical for preventing further spinal damage. Obesity and smoking are known risk factors that exacerbate disc degeneration and herniation (10).
Surgical Treatment Options
Surgery is typically considered when conservative treatments fail to provide adequate relief or if the patient experiences severe symptoms such as loss of bladder or bowel control (cauda equina syndrome) or significant muscle weakness (9).
Discectomy: The most common surgical procedure for PLID, discectomy involves removing the portion of the disc pressing on the nerve. Minimally invasive techniques like microdiscectomy are often preferred as they reduce recovery time and minimize tissue damage (5).
Laminectomy: In cases where the spinal canal is narrowed (spinal stenosis) due to a disc prolapse, a laminectomy may be performed. This procedure involves removing a portion of the lamina (the bony part of the vertebra) to relieve pressure on the spinal cord or nerves (6).
Spinal Fusion: Spinal fusion is a more invasive procedure where two or more vertebrae are permanently joined to eliminate movement between them, reducing pain. This surgery is typically reserved for cases of recurrent disc herniation or severe spinal instability (7).
Physiotherapy for PLID treatment in Bangladesh
Physiotherapy is a widely accepted and effective treatment for Prolapsed Lumbar Intervertebral Disc (PLID) in Bangladesh. Physiotherapy focuses on alleviating pain, improving mobility, and preventing further disc damage. Key physiotherapy techniques used in Bangladesh include manual therapy, spinal mobilization, and manipulation, all of which help to relieve nerve compression and improve spinal alignment. Additionally, physiotherapists use targeted stretching and strengthening exercises to strengthen the core and lower back muscles, thereby reducing the strain on the lumbar discs and promoting long-term spinal health.
Physiotherapy services in Bangladesh are available in both government and private healthcare institutions. Services are provided in hospitals, clinics, and private chambers, where patients can access personalized care from qualified physiotherapists. The role of physiotherapy in treating musculoskeletal issues like PLID is critical for pain management, mobility restoration, and rehabilitation. To ensure effective treatment, it is essential to consult a qualified physiotherapy professional with a graduate-level degree to assess the condition accurately and recommend appropriate interventions.
One leading institution in Bangladesh that specializes in manual therapy is the ASPC Manipulation Therapy Center, located in Mohammadpur, Dhaka. The center focuses exclusively on manual therapy, providing a hands-on approach to treating musculoskeletal disorders. The center’s therapeutic approach is based on the Structural Diagnosis & Management (SDM) technique, which involves a detailed assessment of the patient’s musculoskeletal structure. The SDM technique aims to correct misalignments and structural abnormalities through highly specialized manual techniques, promoting faster healing and pain relief.
Conclusion
In conclusion, physiotherapy is a highly effective and accessible treatment option for the Prolapsed Lumbar Intervertebral Disc (PLID) in Bangladesh. It focuses on reducing pain, improving mobility, and enhancing spinal stability through various techniques such as manual therapy, stretching and strengthening exercises, and electrotherapy. Physiotherapists also play a key role in educating patients on posture correction, body mechanics, and lifestyle changes to prevent future disc problems.
The personalized, non-invasive nature of physiotherapy makes it an ideal option for managing PLID, and with specialized clinics and hospitals providing these services across the country, patients have access to comprehensive care that promotes recovery and long-term well-being. By tailoring the treatment to the specific needs of each patient, the ASPC Manipulation Therapy Center ensures that patients experience rapid recovery. The manual therapy techniques applied are non-invasive, making them an ideal choice for individuals seeking natural and hands-on treatment options without the need for surgery or heavy medication. This center’s commitment to personalized care and its expertise in manual therapy has made it a trusted institution for patients seeking long-term relief and enhanced quality of life.
References
- Adams, M.A. and Hutton, W.C., 1982. Prolapsed intervertebral disc: a hyperflexion injury. Spine, 7(3), pp.184-191. https://journals.lww.com/spinejournal/abstract/1982/05000/Prolapsed_Intervertebral_Disc__A_Hyperflexion.2.aspx
- Boos, Norbert. Spinal disorders: fundamentals of diagnosis and treatment. Edited by Max Aebi. Vol. 1165. Berlin: Springer, 2008. https://link.springer.com/content/pdf/10.1007/978-3-540-69091-7.pdf
- Bronfort, G., Haas, M., Evans, R.L. and Bouter, L.M., 2004. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. The spine journal, 4(3), pp.335-356. https://www.sciencedirect.com/science/article/pii/S1529943003001773
- Carette, S., Leclaire, R., Marcoux, S., Morin, F., Blaise, G.A., St.-Pierre, A., Truchon, R., Parent, F., Lévesque, J., Bergeron, V. and Montminy, P., 1997. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. New England Journal of Medicine, 336(23), pp.1634-1640. https://www.nejm.org/doi/abs/10.1056/NEJM199706053362303
- Caspar, W., Campbell, B., Barbier, D.D., Kretschmmer, R. and Gotfried, Y., 1991. The Caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure. Neurosurgery, 28(1), pp.78-87. https://journals.lww.com/neurosurgery/abstract/1991/01000/The_Caspar_microsurgical_discectomy_and_comparison.13.aspx
- Katz, J.N., Lipson, S.J., Chang, L.C., Levine, S.A., Fossel, A.H. and Liang, M.H., 1996. Seven-to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis. Spine, 21(1), pp.92-97. https://journals.lww.com/spinejournal/fulltext/1996/01010/Seven__to_10_year_Outcome_of_Decompressive_Surgery.22.aspx
- Kornblum, M.B., Fischgrund, J.S., Herkowitz, H.N., Abraham, D.A., Berkower, D.L. and Ditkoff, J.S., 2004. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis. Spine, 29(7), pp.726-733. https://journals.lww.com/spinejournal/fulltext/2004/04010/Measurement_Properties_of_a_Self_Administered.4.aspx
- Modic, M.T. and Ross, J.S., 2007. Lumbar degenerative disk disease. Radiology, 245(1), pp.43-61. https://pubs.rsna.org/doi/abs/10.1148/radiol.2451051706
- Peul, W.C., Van Houwelingen, H.C., van den Hout, W.B., Brand, R., Eekhof, J.A., Tans, J.T., Thomeer, R.T. and Koes, B.W., 2007. Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356(22), pp.2245-2256. https://www.nejm.org/doi/abs/10.1056/NEJMoa064039
- Samartzis, D., Karppinen, J., Chan, D., Luk, K. and Cheung, K., 2010. The association of disc degeneration based on magnetic resonance imaging and the presence of low back pain. In World Forum for Spine Research, WFSR 2010. https://hub.hku.hk/handle/10722/126533
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