NEWSLETTER

MINDFUL POSTURE: Learning Spine Care The Hard Way

by Don English

When I got out of bed that morning to do my sun salutations, my right knee wouldn’t hold straight in a forward fold.  I simply noted it and continued, softening my knee with each uttanasana.  Before breakfast my wife suggested we walk the neighborhood instead of going to the gym as usual.  As we began, I noticed that walking was becoming more and more difficult, so after a block-and-a-half I admitted that I couldn’t continue and returned home. 

            For the next three days, though, I kept my life as near  normal as I could, teaching my usual yoga classes, and painting a large number of heavy wooden shutters, turning and flipping each to paint all sides.  By then the pain had  moved into my leg and I had begun to walk like Groucho Marx.   By the fourth day I couldn’t continue working – it seemed serious so I called my doctor.  An MRI showed the L4-5 disc (the lumbar disc at about the waistband) had herniated and ruptured laterally and to the right.  The ruptured released material from the disc which pressed against the nerve root where it exits the spinal cord causing pain down my right leg. 

            I was lucky to have acknowledged I might have a serious problem when I did, a physician friend later told me, because the longer a person waits enduring the pain, hoping it will go away with home remedies, the more likely permanent damage will be done to nerves and reflexes.       

            The best medical advice boiled down to a few options: First, take pain medication and let the body heal itself.  Second, do the first option and take a series of epidural steroid injections into the site – the hope was it would lessen the inflamation and speed healing (my choice).  The third option was surgery to remove the extruded disc material, thereby decreasing the pressure and inflamation, and speeding the healing.  If there were loss of motor function, or if the bowels or bladder were affected, surgery would have been the first option.  Since this was not the case, the issue of surgery came down to whether or not I could tolerate the pain.  Heroically I said I could.
 
            Spinal surgery today can often be done using minimally invasive laproscopic surgical techniques.  Hospitalization is short and patients may walk out the next day.  But still, surgery is surgery, and there can be problems with anesthesia, no matter how good it may be.  I would be just as happy to get better without the surgery. 

            After I decided against surgery, an orthopedic surgeon confirmed my decision saying, after five years surgical and non-surgical groups typically will be at the same comfort level.  Generally speaking, the non-surgical group will slowly but steadily reach that point.  Their counterparts, however, may deal with pain and problems relating to scaring or other surgical issues.  A friend, whose surgery was three years old, confirmed that in a discussion of his recovery. 
           

Herniations can be difficult to recognize at first, because the initial nerve pain feels similar to a muscle pain.  If the lower back muscles spasm, the feeling of tightness I came to associate with the bulging disc may be completely masked. 

            No two disc herniations are the same.  Small variations of individual anatomies, and the random manner in which discs can herniate, mean they all show slightly different symptoms. A sure sign of a serious problem is pain moving from the spine in the vicinity of the waistband out to the side and down into the leg.  At the onset of such symptoms supported cobras are in order to help draw the bulging disc back into place and to close the intervertebral spaces.  Whatever we do, we should do it carefully, and with humility admitting when we need help. 

            Considering how widespread disc problems are, I am still surprised most of us know so little about them.  It’s a fact – around 80 percent of the population will have some sort of serious back problem during their lifetime.  Approximately 90 percent of those problems will involve some sort of damage – sprain or strain – to muscles, ligaments or other soft tissue surrounding the spine.  Ten percent of those will be more serious, involving degenerative disc disease or herniations.  The majority of those herniations will be posterior, that is, release of disc material to the rear – a smaller portion will be lateral, or to the side.  Both will cause inflamation and pressure on nearby nerves. 

            Those are the numbers but they don’t begin to tell the whole story.  When you tell someone you herniated a disc, they are ready with a story about their own, or a friend’s herniation.  Yet, each story is different.  This one can stand but not sit.  That one can sit but not lie down.  One has muscle spasms of the lower back, while another does not.  Some have difficulty moving between sitting and standing, others say, no.  The one thing everyone has in common is nerve pain into the leg.  Let me hasten to add there could be other serious causes of nerve pain in the leg, so it’s always best to see your doctor promptly for confirmation and proper care.

            When friends heard I’d herniated a disc, they usually said, “You have such good posture, how did this happen to you?”  That was a question I asked myself for the next three months as I waited for the pain to subside.  And I asked it for another three months as I worked with a physical therapist to regain strength and flexibility in my right leg.  The answer was one I didn’t want to admit – it wasn’t my posture that was the problem, it was my ego.  But reaching that conclusion took much longer to arrive at. 

            For a better understanding of what causes these problems, it helps to know how the spine works.  Separating the vertebral bones are pads – the discs.  They act like shock absorbers and are like jelly doughnuts with a tough exterior called the annulus inside is the squishy jelly-like nucleus.  With age the nucleus can become more dense.  As the spine moves, the disc deforms and reforms.  Sometimes it bulges beyond the edges of the adjoining vertebrae and doesn’t return to its normal shape and position.  If the annulus has become weakened, a small amount of additional pressure may be all it takes for it to break, spilling a portion of the disc’s nucleus into the surrounding tissue.  Then as this material presses against adjacent nerves exiting from the vertebrae, we feel pain running down our leg.  Because the disc is not supplied with blood, it cannot heal like a cut in skin or muscle.  It must wait for the annulus to scar over, the ligament to heal itself, and the herniated nuclear material to be isolated and reabsorbed into the body.  All this takes time. 

            The longer the sufferer tries to deny and work through the pain, the more damage is done to the involved nerves and muscles.  Reflexes begin to diminish.  Muscles lose their tone. 

            So why do discs herniate?  And, how can we prevent them?  The answers lie in understanding and maintaining good spinal alignment.  In fact most non-trauma herniations can be prevented by good posture, good conditioning, and good body mechanics.  These are all things we can control. 

            As yoga practitioners, we would like to think we have good spinal alignment.  After all, we preach the subject constantly to our students.  I certainly thought mine was good.  So what happened to me and the others who injure themselves this way? 

            I can’t speak for the others, but my physical therapist suspected that I did not pay enough attention to the finer points of posture.  To carry ourselves properly, the ears line up above the shoulders, the shoulders above the hips, hips over the ankles.  Further, the right and left shoulders and hips should be carried level.  If we carry ourselves correctly, the pelvis bowl is held level (not tilted forward or back), and the shoulders blades are drawn back toward the spine.  If all of this brings to mind images of a soldier standing at attention, we’ve got the picture.  Now all we have to do is maintain this as our habitual alignment whether standing, walking, or sitting – and do it for the rest of our lives.  It’s what I call mindful posture. 

            When we don’t maintain good posture, not much happens for a long time.  The body has a wonderful capacity for accommodating to bad situations.  Over time, the new demands that are placed on our joints, tendons, ligaments and muscles – stresses they were not intended to bear – cause pain. 

            Let’s think of the body as a scaffolding where the load is transferred directly and equally to all legs.  If any part becomes crooked, the load shifts and the entire structure becomes unstable.  When we stand or walk with correct posture, our weight is properly distributed the way nature  intended.  However, when we carry our heads or bodies thrust forward, our shoulders rounded and slouched, our pelvis tilted, our center of gravity shifts.  This shift transfers the weight to parts of the body not designed to carry the load.  Joints become inflamed, minor muscle groups take over the work of major muscles which then lose tone from under-use.  Eventually something has to give – a joint becomes arthritic, a hip becomes stressed, tension develops in the spine, a disc pops. 

            In my own case, a lifetime of conditioning encouraged a subtle component of poor posture.  My physical therapist identified it early.  She suggested my full time job as  painter and paper hanger was part of the problem.  Much of my work was overhead, and for years my back was held in an almost constant state of extension.  My lower back muscles were, therefore, in continuous tension, drawing me into a slight, but permanent back bend.  To compensate my pelvis tilted forward, loosening and stretching the abdominals.  Because I did forward bends the yoga way from the hips, I never rounded my lumbar spine.

            I remember in my first yoga class my lumbar spine was so rigid that when we did spinal rolls, I felt like a human flat tire – flop-flop, flop-flop.  I was a disc waiting to herniate, and all it took was the convergence of the right set of factors. 

            Also, I thought my body mechanics were good enough.  I hadn’t had any serious problems with my back since I started yoga.  If I dropped something I bent at the hips and picked it up – I was stretching my hamstrings.  Obviously, I didn’t give body mechanics much thought. 

            On my last visit with my doctor, I asked him, “What can I do, and what shouldn’t I do?”

            He said, “Go slow.  Take baby steps.  Don’t jar your spine.  Don’t reach back and twist.  And support yourself when you lean, even when you brush your teeth.”  Don’t jar the spine made sense.  So did the part about reaching and twisting, but I puzzled about the tooth brush advice until about a month into physical therapy.  By then I was back in a weekly yoga class when the light went on.  We were doing supta padangusthasana with knees bent and twisting right and left, then repeating it with both legs extended.  The added weight of the fully extended legs sent twinges into my lower leg.  There, if I needed it, was proof of how a small shift of weight outward acts like a lever on the spine.  The tooth brushing advice had to do with the levering action of my body’s weight on my spine.  Similarly, reaching or bending to pick up something is just dumb body mechanics.  It’s not just the weight of the object, but its weight magnified through the lever principle, plus the body’s, or leg’s added weight acting on the spine.  Squatting or flexing the knees now made a lot of sense.  And of course, keeping the spine in good alignment is a must. 

            Yoga practitioners are well conditioned athletes.  But again, proper spinal alignment while doing yoga insures the entire body structure will be engaged correctly, strengthening muscles instead of straining or spraining them.  If we are unfortunate enough to herniate a lumbar disc, our conditioning can help sustain us through the eight to twelve weeks of healing.  During that time, there isn’t much to do except wait for the pain to subside, indicating it’s safe to begin the rehabilitation. 

            I knew throughout the ordeal that I was losing strength and flexibility, but I needed to get active before I could judge how much.  Someone told me you lose ten percent a day, but at that rate I calculated, I should have been a bedridden vegetable.  Then I heard about a presentation by the Human Performance Lab at East Carolina University.  The Lab had conducted a study on two groups of individuals.  The first consisted of people who did not exercise regularly, the second of those who did. Both followed an exercise regimen for two weeks, and then stopped exercising completely for two weeks.  At the end of that time both groups had lost their conditioning.  The big difference between them was that the regular exercisers returned to their previous level sooner. 

            The conclusion was simple – we can’t store fitness.  It’s startling, it’s almost intuitive, but it was not real until it happened to me – until my right leg could hardly  support me, until I could not get up from a squat, until I needed a cane for support.  I estimated I lost about thirty percent strength and flexibility overall, and sixty percent in my right leg – the one not getting the proper nerve messages. 

            I asked my physical therapist about this loss of strength and flexibility.  She said in her experience the more athletic the person, the faster they lose conditioning.  I asked, tongue in cheek, if that was an argument for not exercising?  “No,” she said, “it means you have reserves others don’t have.  That you will come back quicker.” 
What are the lessons for yoga practitioners?  We must be careful.  We must remember that the Laws of the Universe apply to us as well as our students.  As we age, our bodies change and we must adapt our practice accordingly. 

            There is no reason why a person who has had a healed disc – no pain and moving normally after eight weeks or so – can’t do all of the yoga postures.  However, those people must be careful to maintain good alignment and spine stability at all times.

            Any muscle tightness at the site of the injury must be assumed to be a bulging disc and treated appropriately.  All of us, but especially those with recent (three to five years) disc problems, must listen to our bodies.  We need to do short series of flexions and extensions (rag-dolls and cobras) now and then to draw the bulged disc into place.

            Bulges are normal, and we do counterposes to move the bulged disc back into place, not just to stretch the muscles.  Mix up the postures in class.  As often as possible let back bends follow forward bends.  Don’t do twists until the spine has been flexed and extended in an attempt to stabilize the discs. 

            We can help our students learn the difference between feeling a sensation, and feeling pain.  That’s not an easy task.  Probably knowing our students is the best approach. 

            Loss of strength may be the most serious problem facing someone returning from this injury.  The reason is simple.  A lumbar disc herniation means an extended period of inactivity – two or more months – with consequent loss of muscle tone and flexibility.  While it may be obvious the legs are weak, so is the rest of the body.  Postures that used to be easy will be difficult when returning to the mat.  We need compassion for those coming back from injuries so they do not push too hard, too fast. 

            Supervised weight training is a good way to regain strength more quickly, but care must be taken to maintain good alignment.  This is where a physical therapist can be of
great assistance.  They know how to help the injured back and which muscle groups to work with first. 

            As we’ve discussed, non-trauma disc herniations are the result of posture problems.  The physical therapist can help identify the problems and suggest solutions.  Remember the human body is dynamic and with timely intervention and proper guidance, it can and will correct itself.

            If it happens to you, see your doctor, get professional help with your rehabilitation, and know you will be on reduced activity for several months.  Plan ahead for that eventuality. 

            Finally, there is a psychological component – fear of re-injury.  Every new activity works things inside the body differently.  These new activities bring twinges in the affected areas, and the question is always present, “Is it happening again?”  A physical therapist can be a great cheerleader, urging the patient along at just the right pace toward full recovery. 

            While complete recovery may take several years, I only do that Groucho Marx walk for parties.  By taking baby steps, reintroducing activities one at a time, and maintaining mindful posture, I hope to be teaching yoga classes for many years to come.  Running may not be in my future, but otherwise, the outlook is bright.        

Well, not as bright as I thought when I originally wrote those words, because a year and a day after the original injury, I was dealing with the pain all over again.

            I stepped out of the car after driving for an hour-and-a-half only to discover that couldn’t stand.  What caused this to happen?  I have no idea.  But this time I discovered that riding my bike relieved the pain, if only temporarily.  I also knew that it would help keep my legs strong until the problem was resolved. 

            When not riding the bike, the pain was excruciating – like having an electrical current of various strengths running down my leg simultaneously.  The only way I could sleep was draped over an exercise ball. 

Once again I was limited in my ability to get around and do the things that I wanted to.  With time to reflect again, what I finally pieced together was that the original trauma to my L4-5 disc had really begun seven months before the original rupture. 
            I was teaching a yoga class.  We were sitting on the floor and had moved into upavishta konasana in preparation for janu sirsasana to the left.  I turned toward the left and lowered my body toward my left leg.  As I was getting into position, I felt a sharp stab like an ice pick in my lower right spine.  I came up immediately, and was very careful for the next several weeks and months. 

            Seven months and countless yoga classes later, I was teaching yoga to a class of teenage boys.  I wanted to get really deep into janu sirsasana to show them how our forty year age difference didn’t matter.  And I got stabbed again. 

            I finished the class, and went about my day.  No problem.  It wasn’t until the next morning when I got out of bed to do my sun salutations that I had the first indications that something was wrong. 

When the second injury occurred the next year I was out of town.  I found a chiropractor who administered a therapy called IDD – Inter-Discal Distraction.  It’s like an updated version of the Medieval rack.  The patient lies on a table, upper body held stationary, while the lower body is attached to a computer controlled motor via a strap that pulls the hips at an angle specific for your injury.  The theory is that by decreasing the pressure at the site of the injury, the pain is relieved, and healing is encouraged by stimulating blood flow to the injury. 

            The rack got me well enough that I could get home without too much trouble.  And it turned out that my neurosurgeon had recently installed a similar machine, so I continued my therapy with him.  However, over the four weeks of therapy, I saw little overall improvement.  At its end, I was ready for surgery. 

The surgery he planned was called a right lateral micro-endoscopic discectomy.  Briefly described, the surgery goes something like this: 

            Through an incision less than an inch long, a guide wire is inserted to locate the affected disc.  The surgeon uses a special type of x-ray machine called a fluoroscope to position the guide wire directly over the herniation site.  Sequential tubes are inserted over the guide wire, dilating the tissue down to the vertebrae.  The wire is removed.  Then a tubular retractor, through which the surgery will be performed, slides over the dilating tubes, which are also then removed.  A surgical light and camera are passed through the tube and surgical instruments are used to clear away bone and tissue accessing the spinal canal.  A nerve retractor is used to gently move the spinal cord away from the herniated disc.  The herniated portion of the disc is removed, and the area is cleared, allowing room for the nerve to move back to its normal place.  The instruments and retractors are removed, allowing the tissue to close in and around the site.  Finally, a small bandage is placed over the incision site.

            As soon as I regained consciousness, I knew it had been successful.  I could lie flat on my back, and there was no pain – not even any low-level background pain.  Within six hours of surgery I was up walking around and had only one pain medication immediately after surgery. 

            Recovery was much swifter this time.  There was some loss of strength and flexibility, but it came back quickly.  Within sixteen weeks of the injury and 10 weeks from surgery, I was back to yoga.  And three months after that, I my strength and flexibility were at their pre-injury levels. 

           
What did I learn from all of this?  I learned that I was lucky.  My residual deficiencies are few: slight numbness on the outside of my right big toe, and the knee-jerk reflex hasn’t come back yet.  I followed my surgeon’s advice and waited 10 weeks before I returned to yoga, but yoga has helped floss the nerve at the surgery site to prevent scarring and pain at the site.  Interestingly, I learned that the original injury to the annulus had healed by the time of the surgery but that the extruded material had not been completely reabsorbed by the body.  So, as the extruded disc material had begun to dry it probably shrank away from the nerve root easing the pain.  Then something happened while driving that caused it to begin to press against the nerve again bringing back the pain. 

            I also learned a lot about the body, and particularly the lumbar region of the spine.  I learned how easy it is to sustain an injury to the lumbar spine located as it is between the less flexible thoracic spine and the totally inflexible sacral spine.  I learned the importance of being in good condition before an injury, and the importance of returning to 100 percent.  I learned to make my body, particularly spinal alignment, a part of my mindfulness practice.  I learned how precarious good health is.  I learned that if I’m not careful, my ego can get me into trouble faster than I can think. 

            And finally, a year after surgery, I’m back to doing my sun salutations upon rising.