Annular Tears. Are They Serious?
The MRI results are in. There is an annular tear at L5/S1. That sounds terrifying! It could be called an annular fissure (not quite as terrifying) but these are actually a common result of aging, and sometimes trauma, to the spine.
Discs are the shock-absorbing cushions between each vertebra of the spine. Surrounding each disc is a strong outer ring of fibers, called the annulus fibrosus. The inside is a soft, jelly-like center, called the nucleus pulposus. The annulus is the strongest area of the disc and the outer third of the ring is enervated with pain fibers.
If there is a tear or an opening in the annulus, it can be asymptomatic to extremely painful. Symptoms can be similar to a herniated disc. They may include pain, numbness, weakness and/or electrical sensations that travel down one leg or arm. The tear may heal with scar tissue, but it will always be more prone to future tears. It could also lead to accelerated degeneration to the disc itself.
Diagnosis and Treatment
Though an annular tear is often diagnosed on an MRI, many physicians also order a discogram to see if this is the actual pain generator. Though popular in the past, discograms are now considered by many to be to unnecessarily painful, not completely accurate and may lead to accelerated degeneration of the disc.
Treatment for an annular tear or fissure is generally conservative. A physical therapy program, low-impact exercises, anti-inflammatories are usually effective. Should these measures not be effective, steroid injections or even surgery may be recommended.
The best advice: give it time and keep moving. Like many spine problems, the body will look after itself.
For more information and Dr. Shim’s opinion on annular tears, high Intensity zones and even discography, please click on the above video.
- Motiei-Langroudi R, Sadeghian H, Seddighi AS. Clinical and magnetic resonance imaging factors which may predict the need for surgery in lumbar disc herniation. Asian Spine J. 2014 Aug;8(4):446-52. PubMed PMID: 25187861
- Simon J, McAuliffe M, Shamim F, Vuong N, Tahaei A. Discogenic low back pain. Phys Med Rehabil Clin N Am. 2014 May;25(2):305-17. PubMed PMID: 24787335
What is an annular tear? I'm Dr. John Shim, and today I'd like to discuss a very intimidating sounding term. Many of my patients have had episodes of neck or back pain, and during the course of evaluation a test called an MRI was obtained. Oftentimes, the studies identify things like bulges and herniations. If you have watched my prior videos you'll know that it's a very common finding on MRIs, and whether you do or do not have pain you - can't find them. What scares many however is the term "annular tear." It sounds very painful. It sounds like a big problem. The truth is it may or may not be an issue. Let me explain. To summarize basic disc anatomy there are two main components. There's a softer inside of the disc called nucleus. It's full of water, it gives the shock absorbing properties of the disc. There's also the outer component of the disc called the annulus. It's a very tough ropey structure that holds the nucleus into the center of the disc. If you have a disc herniation, by definition the nucleus material has to come out of its normal central location, and through the annulus or a break through the top or bottom of the disc bone interface called the end plate. This break in the annulus can be called a "annular fissure" or the more scary term is "annular tear." The medical community is still trying to identify these annular tears through various diagnostic studies. The best way to identify the breaks is to inject a disc with dye material, and then because of the break the dye material can be seen escaping a disk on cross-sectional cat-scan. That is the definitive diagnosis of a break in the annulus. To do this test, it can be very painful, it is invasive, and unfortunately the latest information indicates that doing the discogram procedure itself can potentially lead to accelerated disc degeneration. Yes, this procedure is called a discogram, and it does remain controversial, and there are concerns that the procedure itself will cause future degeneration. MRI studies are less invasive. In the 1990's as MRI studies were becoming more commonly used findings towards the edge of the annulus called high intensity zones were initially thought to indicate new breaks in the annulus or even indicate pain coming from the annulus. This too became a very controversial issue. In the 1990's many people had surgery for the so called high intensity zones. Unfortunately, the results were not as predictable as thought. Now there have been further studies indicating these high-intensity zones may not in fact indicate an annular tear. Long term studies of these high-intensity zone findings found that they may never actually go away. So, there's really no way to know if these findings demonstrate a new or an acute problem. From a diagnostic standpoint, in my opinion, there are still too many unknowns and associated risks to try to identify an annular tear. From my perspective as a spinal specialist because the fissure in the annulus is necessary to create a disc it is my opinion that in general if you have a disc herniation you will likely have an associated annular fissure or tear. The other possibility of course is a break in the end plate, that allows a central nucleus to come out of its normal position. The term "tear" emotionally associates with some sort of traumatic event. What we know of disc herniations is that they can occur with what sounds like very trivial motions: sneezing, coughing, bearing down well in the bathroom, twisting in bed, reaching for an object. These are very trivial appearing motions, but are associated with herniated disks. While it is true that activities such as a significant fall, a direct blow, or a car accident can cause herniated disks, everyday activities of life also are just as likely to cause these herniations. The more the medical community learns the more we realize that genetics is playing a significant role in development of disc abnormalities. In my opinion the term annular tear on MRI study may or may not have any significant bearing on your current condition. The term annular tear on MRI is typically associated with the so called high-intensity zone which we now know may or may not be symptomatic. In other words, may or may not be the source of your pain. While the term annular tear sounds scary it may not be the source of any pain. As I stated this high intensity finding was used as an indication for surgical management in the past - as of 2019 the finding by itself is no longer an indication for need for operation. The finding by itself does not make you a quote "candidate for surgery." If you have an annular tear on your test results do not be scared. Get a comprehensive second opinion by a spinal specialist. This is Dr. John Shim, discussing annular tears. I hope this gives you some comfort when you read that scary testing result. If you find this information helpful - please Sign Up for our video channel. We welcome suggestions for further videos. Thank you.