I Have What?
Hi, my name is Dr. John Shim, and I would like to talk about disc bulges found on MRI. On a daily basis, I have friends and acquaintances coming to me, fearfully telling me that their doctor ordered an MRI, and it showed a slipped disc to their spine. Because I know that finding seems like a serious problem, I'm very careful in my response to that statement. What the general population may not know is that disc findings on MRIs are expected for anybody over the age of 40. In fact, many episodes of neck and back pain are not because of a disc problem, but rather because of a pull or a stretching of the muscles, ligaments, and tendons holding your spine bones together. It's not a slipped disc that was identified on the MRI. As a spinal specialist, I know that findings on MRIs may not have anything to do with your pains. At the same time, those findings can be cause of specific complaints and findings. A lot depends on the pains, and the actual physical findings identified by your doctor. With proper counseling most people will understand that MRI findings such as a disc bulge or small herniation will not likely be a significant problem. And in fact, those are expected changes associated with age, genetics, and an active lifestyle. MRI is a pretty good screening tool to make sure you do not have anything bad like a tumor or infection. At the same time, it's a very costly test, and based on your complaints and medical history most physicians will already have a pretty good idea if you have something significant. So, if you have disc findings on your MRI, but if you're getting better, and your complaints are not that severe - it's highly unlikely that those disc findings are going to give you significant long-term concern. To me, often It's the anxiety of not knowing what's on the MRI that causes the increase in pain. For most people, as long as there's not anything significant as long, as there's not a significant weakness, as long as there's not a severe pain or numbness - an immediate MRI is not necessary. That's why it's now recommended to wait at least six to eight weeks before getting an MRI for what we'll describe as a straight forward neck and back pain episode. Right now, scientists are testing ways to identify whether MRI findings are actually a cause of pain at that time. Unfortunately, these testings still require sampling tissue, and therefore, needles and injections around the area of concern are necessary. But the future is to explore whether pain is caused by findings on studies such as MRIs. The medical community is working hard to answer that question. This is Dr. John Shim, talking about MRI findings. I hope this video gave you some helpful information.
The report is in front of you. And it looks dire. Degeneration, bulges, herniations and annular tears. It sounds terrible!
I am not a radiologist but I have seen a lot of MRI’s and MRI reports over the years.
I have taken many courses and have been privileged enough to work with several surgeons who read the films with me, so I am going to explain this so a “regular Joe” can understand it. This is only to help people understand that many of these phrases and words we use are not quite as scary as they sound.
A normal disc. Normal defines disks that are of proper size, shape and color on the MRI. They would have a complete hard outer covering and would remain in the “disc space” with no part of the disc going further than the vertebra above and below it. To have all “normal discs”, you would probably be very young, not play sports and have a sedentary job. To be quite honest, after 30, it’s a pretty rare occurrence.
An annular tear or fissure is when there is an opening in the hard outer covering around the disc. Sometimes it leads to a disc herniation, sometimes it doesn’t. They generally heal themselves but can often lead to disc degeneration because the normal fluid in the disc leaks out. The word “fissure” is preferred as it does not imply trauma.
A disc herniation refers to a displacement of disc material beyond the normal confines of the disc. The herniation can include disc material, cartridge, bone or annular tissue (or a combination of all of these). The herniation is further described as either a protrusion or an extrusion.
A protrusion means that the base of the herniation is wider than the rest of it and the outer fibers of the disc outer covering (annulus) are intact.
An extrusion is when the base (or neck) of the herniation is narrower than the piece that comes out of the disc. The hard out covering is torn and the piece may hang down or float up in the spinal canal.
A bulging disc is something no one seems to really agree upon. In 2014 The American Society of Spine radiology describe it as “annular tissue projecting beyond the margins of the adjacent vertebral bodies, over more than 90° circumference”.
It also says a circumferential bulge involves the entire disc circumference and an asymmetric bulge does not involve the entire circumference but more than 90° of the disc.
In other studies and articles a bulging disc is not considered a form of herniation but a descriptive term of the shape of the disc contour. Symmetrical bulging disc is when the whole disc has tissue beyond the edges and an asymmetrical bulging disc is within the bulging is only noted from one part of the disc still greater than 90°.
Needless to say, every radiologist, according to age, training and vernacular would describe a bulging disc differently.
The big thing to remember is that no good surgeon “operates on an MRI” which means we look at the patient and see what their symptomology is and compare it to the MRI. A person could have 3 herniated discs and no pain or weakness. They would most likely not require surgery. Someone else could have a small disc that presses directly on a nerve and not get better over time, or with conservative care, and would require surgery.
So, calm down. It sounds bad but very often that horrible sounding MRI is normal for someone of your age and circumstance. Remember a disc herniation or a disc bulge is only a problem if it is causing one.
- Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017 Apr;17(4):554-561. PubMed PMID: 27867079