Managing a Severe Disc Herniation at 40: A Clinician’s Perspective
Hi! My name is Shannon and I’m an orthopaedic physiotherapist in the Annex neighborhood of Toronto, Ontario. I own Resilience Physiotherapy in Toronto.
I have been rehabilitating myself through a pretty significant disc herniation since the beginning of this year. Coincidentally, I also turned 40 earlier this year - if this is how I’m starting my 4th decade, I’m going to start counting backwards!!
The following posts are a chronicle of sorts of my tumultuous healing journey that has contained many ups and downs. Recovery is never linear and I’m assuming if you’ve found this blog that you may be going through something similar.
Sometimes, hearing someone else’s experience can be educational or can also be comforting to know that you’re not the only person in the world going through this. I intend on sharing my journey with you until I get this injury dealt with once and for all!
Resilience Physiotherapy is the name of my practice and over the months of 2024 I intend on being a real life example of what the word ‘resilience’ actually means.
The Backstory
The first time that I injured myself was about 10 years ago with poor ergonomics while treating a patient (had to learn my lesson the hard way).
I am pretty sure I herniated a disc at that time, but I was able to get intensive physiotherapy and work with a clinical pilates instructor to manage things conservatively and recover without any further intervention needed.
Manual therapy, acupuncture, Gunn IMS/dry needling, and core/glute strengthening have been my immediate action plan to manage any low back flare-up ever since.
Whenever my low back would act up, I never hesitated to book for treatment immediately to keep things at bay. I was able to return to most activities that I love since that initial injury, but running and deadlifts are the two activities that would consistently flare me no matter how much coaching I got, or how closely I monitored my form.
I eventually just eliminated both from my fitness regime as I replaced running with spinning and weighted deadlifts with many other glute and hamstring exercises.
The set back that I had each time I would try either of the two things just wasn’t worth it to me! Bi-weekly pilates workouts have been non negotiable for me since the injury and strength training and spinning are worked in around those workouts.
In the past 10 years, I’ve had two kids and started my own business so there have been many stressful and also many amazing times.
I have rehabilitated from two C-sections and a major surgery to remove the excessive amount of varicose veins that formed during both pregnancies that were seriously impacting my circulation and causing loads of discomfort.
Overall, I’m a pretty health-conscious individual who prioritizes eating well and staying active and have no underlying health conditions.
Low back issues and specifically disc herniations leading to stenosis (spinal nerve compression) are issues that seem to run deep in the Littlejohn family tree. Three of the four of my dad and his siblings have had lumbar surgeries in their 40s and 50s. While I would not say that genetics are the primary indicator that you may experience a disc herniation in your life, it certainly is an interesting observation in my case!
In a systematic review done by Filho et. al. they cited that “recent studies have pointed out that the genetic influence is the main determinant in the development of degenerative disc disease”. In the introduction they state that “These features of degenerative disc disease multiply the chances of fibrous annulus wall ruptures, allowing the extravasation of the nucleus pulposus and the compression of neurological structures. (1, 2)
At the end of 2023, I found myself diagnosed with pneumonia, which is something that I really only thought that older folks contracted! Man, I can honestly say that I don’t think I’ve ever felt so sick in my life! The fever, chills and cough were nothing like I’ve ever experienced. I was in bed for 2-3 days straight and antibiotics helped to halt the infection, but the intense coughing fits continued for almost three weeks as my body cleared out all of the ungodly looking crap out of my lungs!
Within the first week I would feel nerve pain shoot down the back of my right leg to my foot every time I coughed and tried to brace myself and lift my leg to soften the blow. One day while I was driving and running errands, I got into a coughing fit and felt a searing pain shoot into my right glute. When I got out of the vehicle I could barely put weight on my right leg and that worsened over the course of the weekend.
I was confident I had herniated a disc around L5 because of the location where I was experiencing the pain. I booked two emergency acupuncture sessions and physiotherapy that week.
Physio included very gentle manual therapy, taping and IMS and I also started up sessions with the osteopath who works in the same building as me. I continued weekly physiotherapy and osteopathy and things slowly started to improve, but I was consistently shifted to the left, primarily weight bearing on my left leg and experiencing pain, numbness/tingling into my right lateral leg and foot consistently by days end. I managed my symptoms as best as I could with over the counter medication Robaxacet and Advil as needed.
My symptoms didn’t present how one may expect a disc herniation to present. Normally, disc herniations don’t like flexion (bending over) and leaning backwards is a position of relief, but flexion was my jam. Child’s pose, knees to chest and being on hands and knees in four point, were the positions of comfort that brought me relief. Extension which is essentially a back bend sent pain right down my leg!
This baffled the practitioners that were treating who agreed the disc was irritated and that the nerve was getting impinged elsewhere, but they weren’t convinced of a herniation because of the presentation.
February rolled around and I started to be able to tolerate 20-30 minutes of mat Pilates exercises that targeted core and glute strengthening. I was able to celebrate my 40th birthday and go on a trip with my family to the Dominican Republic. I still had pain by day's end and managed it with a more intense prescription anti-inflammatory called Toradol as needed (prescribed by a doctor).
Sidenote: Toradol is quite hard on your stomach and is not meant to be used for a long period of time. I saw one of my physiotherapists the week after I returned and through a discussion with him, I expressed my concerns over the fact that I was still experiencing the numbness and tingling into my leg and foot. He urged me to get a referral for an MRI as soon as I could. He was concerned there may be a small fracture or a big piece of disc or cartilage that was sequestered (broken off) and interfering with where the nerve was exiting.
I saw a GP who referred me for an MRI and got the number of the MRI department at the hospital.
Now, here’s a hot tip that I always share with my patients regarding imaging. Once the request for MRI is faxed in, call the MRI department to let them know that you are flexible to come in at any time for imaging and to ask if there are any cancellations that day.
We are fortunate in Canada to have a publicly funded healthcare system, but in Ontario our current government has made a huge amount of cuts over the past 5 years and wait times are growing longer by the month. I was told that the wait for an MRI in Ontario was 8-10 months but as luck would have it when I called 2 days after the request was submitted and they had a cancellation for 6:30 am the next morning so I jumped on it!
The results of the MRI showed that I had a disc herniation that was extruding centrally into the spinal canal and into the right lateral recess where the L5 nerve root is supposed to exit and that portion of the herniation was also touching the L4 nerve root. The herniation also was touching the left L5 nerve root and causing mild to moderate narrowing on that side but interestingly I had minimal to no symptoms on the left side of my body.
It also showed a second herniation at L5/S1 touching the left S1 nerve root, but again my symptoms weren’t on the left side of my body! This is important to note as it shows that just because someone has a disc herniation, it doesn’t mean that they will have symptoms!
Part 2: The First Flare up - Early March 2024
So the week after I had the MRI I had been trying to progress my workouts to add a little load (weight) and I could tell that my back didn’t like that as it slightly aggravated the symptoms that I was having down my right leg so I backed off.
Unfortunately that same week on a walk to school with my kids I gave my 4 year old daughter a boost up a hill and really got myself into trouble. Two days later I was barely able to weight bear through my right leg without pain shooting through the entire thing and needed to cancel my day and go straight to my nearest ER.
They put in a referral to a neurosurgery clinic at the sister hospital that had a neurosurgery department and gave me IV Toradol and Morphine to manage the pain.
Over the next few days with rest and medication I was able to get my symptoms to calm down a bit and I started a medication called Pregabalin at the direction of my GP as it really helps with nerve pain, but takes a few weeks to really take effect in your system to work it’s magic.
I had her put in a referral to a program in Toronto called the Rapid Access Clinic for Low back pain. If you qualify for the program, you get assessed first by an Advanced Practice Practitioner (physio or chiro) in the community and they determine whether you’d be candidate for referral to the hospital. I had my assessment within two weeks of the referral and he referred me to Toronto Western Hospital to be seen by the surgical team to assess whether I would be a surgical candidate.
At that appointment I met with the Advanced Practice Physiotherapist who was the surgeon’s right hand person. He showed me the cross section of my MRI at L4/5 and it literally looked like there was a giant cork of disc exactly where my L5 nerve was supposed to be exiting the spine - no wonder I was in so much pain!!
He explained that if I wanted to continue to manage things conservatively it would likely take about 9 months for my body to fully reabsorb the herniation and for things to hopefully go back to normal.
Alternatively he agreed that I was definitely a surgical candidate if that was a route that I wanted to go. I was not super functional by days end at that point and the pregabalin hadn’t kicked in, so I asked to be referred to the surgeon and he also put a referral in for a cortisone shot to help with my pain in the interim.
So two days later I got a call from a pain clinic but ironically it was from a referral from the neurosurgeon that the ER doctor had referred me to at a different hospital!
I accepted a consult a week after and in the interim the Pregabalin (nerve pain medication) had started to take effect. That in conjunction with occasional osteopathic treatments had significantly decreased my symptoms.
I decided to still go ahead with the cortisone shot and received it mid April. It initially flared my leg symptoms a bit for about 24 hours then once that settled it dramatically improved my symptoms. I wasn’t 100% but I was able to wean down to one pregabalin tablet vs two and was only taking about 1 advil/day to manage any nerve pain I was having. I was able to get back to 20-30 minute pilates workouts focusing on core and glute work to rehab once again.
I was feeling so good that there was no way I would consider a lumbar surgery but was still wanting to have the consultation with the surgeon to see what he had to say about my case.
Part 3: The Second Flare-up - Early May, 2024
May 3, 2024: In an extremely idiotic move 2 weeks after my cortisone shot, I helped out with a t-ball practice for my 7 year old son’s team.
I was feeling quite good and really did not think that a t-ball practice would flare my symptoms. What I didn’t account for was that I would be throwing and catching balls for an hour that were thrown all over the place by 7 year olds who sometimes have trouble hitting a target.
I didn’t have much discomfort while I was at the practice and that I have to say is the trickiest part about nerve pain. You don’t really get feedback that you are hurting yourself until the next day. I could tell my right leg was irritated afterwards, but was hopeful that by increasing my anti-inflammatories (Advil) I would be able blunt the inflammatory response.
Well by late into the next day it was very apparent I had done a bang up job of flaring the disc once again. Believe me when I say that no one had to say I told you so. I felt like the world’s biggest idiot - I of ALL people should have known better.
It’s so tricky though because if you’re reading this you may think, why the heck would she risk everything over a t-ball practice?? The answer is that I was feeling good and coaching T-ball is something that means so much to me and my son. It’s our special thing that we do together. I played competitive Fastpitch growing up and a baseball diamond is my happy place in the summer. I love it and have so much fun coaching which is why I was optimistic I could handle it.
Anyways, needless to say I am throwing everything at this flare up to try and get the inflammation to calm down quickly. Icing, increasing my nerve pain medication, taking advil around the clock etc.
It is sooooooo hard as an incredibly active person with a very active job to just take it easy. I want my normal life and body back where I am free to jump, dance, workout and play with my kids as much as I want to without feeling like this fragile individual who may break with any sudden movement or one bad decision. If I am able to get things calm again, I am vowing to act like a sedentary princess for the next 6 months. It may kill me in the process, but I need to keep my eye on the prize and focus on the long game of healing and being able to return to everything I love next year.
I called the hospital and have an appointment with the surgeon to discuss my case in two weeks, but honestly, taking two-three months off to recover from a lumbar surgery is really not high on my list of ‘to-do’s’. The numbness in my foot is still there but seems to have improved a bit post cortisone shot. I have a follow-up call with the doctor who gave me the cortisone shot next week so I am keen to get his advice on next steps for the bonehead physiotherapist who is a horrible patient!
2024 is not shaping up to be my best year yet, but fingers crossed I can start to salvage it!
May 10, 2024: So the day after I wrote the last entry I walked my son into his Tball game in High Park because the park is not accessible to cars on weekends. I simply stood and sat in the dugout letting kids know who was up to bat next and did no throwing/catching etc. This was enough to get my nervous system firing on all cylinders and I have barely been able to walk for a week!
I’m on all kinds of different medications and have doubled the nerve pain meds (pregabalin) once again with the doctor's approval. I have done acupuncture, osteo, physio and red light therapy this week. I think the increased pregabalin dose does seem to be making a difference and I’m laying low and barely leaving the house for three days so let’s see if I can get my system to calm down.
I spoke with the doctor at the pain clinic this morning and we are going to be trying a repeat cortisone injection in two weeks to see if we can get me back to a comfortable state.
My appointment with the neurosurgeon is Tuesday so I’m interested to hear his opinion. My question to him is simply going to be, if I try to manage this conservatively, get the pain calmed down again and vow to do nothing out of the ordinary for 6 months, will my body be able to reabsorb the giant chunk of disc that is suffocating my nerve at the moment? I truly wonder if I am prolonging the inevitable (a microdiscectomy).
I would be so upset if I wait 6 months and then flare again when it seems like the coast is clear to resume more of my regular activities. I feel like such a fool for screwing everything up but I am such a typical patient. There is no use looking backwards, I can only look ahead and hope that I am pain free again shortly.
Nerve pain is honestly debilitating. It’s sharp, shooting, knawing, strangulating and so painful by the end of the day that standing up for any length of time brings me to my knees.
The current state of my low back is presenting as what we call stenosis. If I’m sitting or in any type of flexion (bending forward) I get relief. Childs pose, knees to chest and four point on hands and knees offload the nerve and bring me relief.
When I’m upright and the vertebrae are loaded by gravity, the nerve gets pinched and immediately shoots pain down my right leg down to my foot. I have always been empathetic to my patients, I think it’s a quality that any good therapist should possess but the past 4.5 months have given me a whole new appreciation for those experiencing radiculopathy and nerve pain. It is the absolute worst!! It’s debilitating and literally brings you to your knees.
PART 4: Surgical Follow-up - May 14, 2024
So the day before I was supposed to go see the surgeon I got an email saying that unfortunately he had to cancel me the next day because of a scheduling conflict and that I could reschedule for the end of the month.
In my 15 years of helping patients navigate our healthcare system, I know that you HAVE to advocate for yourself in this system to get the help you need sooner rather than later. I pushed back with an email and told them that I had booked the entire afternoon off and would be able to come at any point.
They told me to come at 3 pm and that there was a small chance I wouldn’t get to see the surgeon but could try. I took my chances and waited a long time to see him.
Unfortunately I had to go move my car so it wasn’t towed off of the major street it was parked on after 4 pm which left me in a ton of pain as walking has been very difficult as of late and flared my symptoms.
I met with him and consented to the surgery after hearing the risks. I was told he was booking into the fall which was a bit of a blow at the time as I was in immense pain.
After a solid cry in my car and an evening of whoa as me, why the hell is this happening to me and what did I do to deserve this, I saw the fall surgical date as a positive. I saw it as motivation to get myself back to a pain free functional state between now and then, commit to being super cautious of the activities I choose to do, then make the call whether I need the surgery or not.
I had been trying to push through and treat part time since I had re-aggravated myself, but that night I finally took the advice of my physios, friends and family and cleared the rest of my week. I have rested and done a ton of rehab work to try and centralize the disc and resume gentle core strengthening that I can tolerate. I had two sessions of physio with a colleague close to my house and can happily say I turned a corner and the inflammation and pain finally started to calm down.
If you’re reading this, I’m sure your natural reaction is to think, “ya, no kidding you felt better, you finally let yourself slow down and heal”. This should be a no-brainer, but when you’re a business owner and self-employed with no sick days, making those decisions has a financial impact.
My physio said it best though that at the end of the day it’s a few weeks and money is just money. If I kept pushing I could’ve very well stayed in my flared state for weeks. In the past year I expanded my space/practice and hired two part-time physiotherapists that have been very helpful. I’m proud that I was able to pay off my renovation costs in the first 8 months so that gave me a lot of relief to not have massive lines of credit calling my name.
Going forward I need to be triaging my next few weeks, blocking many breaks in my schedule, rescheduling patients that require larger more physical movements like mid/low back (thoracic and lumbar) manipulations as I know trying these manual therapy techniques will do nothing but flare me.
I truly never feel that my job is that physical until I’m pregnant or injured then boy oh boy does it resonate. Staying strong and healthy is imperative to me continuing with the physical career I have chosen. When I make the final decision about the surgery when the date comes up, I need to take this into consideration. If having a surgery is going to help prevent future flare ups like these then sign me up. Nerve pain is truly debilitating and you can’t fully understand until you’ve gone through it yourself.
No one has a crystal ball that tells us whether my body will have the capacity to reabsorb the part of the jelly filling that is currently strangulating my L5 nerve root or whether I will end up needing the surgery in the end. All I know is that I am not prepared to live life on the sidelines forever. For the rest of this year I can commit to doing just that, but being sidelined indefinitely just does not work for me!
REFERENCES:
Genetic Influence in Disc Degeneration - Systematic Review of Literature *Ricardo Vieira Teles Filho, Guilherme de Matos Abe, and Murilo Tavares Daher
References from the study
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