An annular tear, sometimes referred to as an annular fissure, causes back pain and discomfort and may also cause mobility difficulties and tingling and numbness in the buttocks, arms and legs. It most commonly affects the lower back, or lumbar spine, and can become progressively worse. Patients with an annular tear often report that they can find no relief no matter what position they try, often finding that even sitting still brings no comfort.
If you’re experiencing low back pain and you’re not sure what’s causing it, you may have an annular tear. An annular tear MRI (magnetic resonance imaging) scan could therefore be helpful in getting a diagnosis so that you can explore your treatment options. Treatment for an annular tear ranges from physical therapy and anti inflammatory medications to steroid injections and minimally invasive surgical treatment.
Here's everything you need to know about annular fissures and how to get a definitive diagnosis and find the right treatment to relieve your symptoms.
What is an Annular Tear?
The spine is made up of 33 bones called vertebrae that are connected together via joints called facet joints. Between each vertebra sits a spongy disc called an intervertebral disc. These discs cushion the spine, absorbing shocks and impact, and allowing us to bend, twist, lift and move freely.
Each intervertebral disc has a soft, gel-like centre called the nucleus pulposus made primarily of water and collagen. The harder outer layer of each disc is called the annulus fibrosus and is made up of tough, fibrous connective tissues called annular fibres.
If one or more layers of the outer annulus fibrosus become worn or damaged (usually through age-related wear and tear or an injury, but we’ll discuss these in more detail further down), it causes what’s known as an annular tear. In the early stages, you may not experience any pain or discomfort. However, as you go about your daily life, more and more pressure is gradually applied to the affected intervertebral disc, and the annular tear can then cause the soft inner gelatinous nucleus pulposus to leak out. Over time, this can cause a disc bulge and eventually a disc herniation (when the soft inner contents of the disc completely push through the tough outer) that will cause pain and difficulty moving about freely. If the nucleus pulposus leaks in a certain way, the resulting herniated disc may then press against a nearby nerve root, leading to a very painful pinched nerve.
Also adding to the risk of annular tear pain is the presence of granulation tissue, a type of tissue formed during the healing process. When the annular fibres initially become damaged, granulation tissue will form in order to help fix the damage. But tests have shown the presence of granulation tissue in the so-called high intensity zone of an annular tear and subsequent disc degeneration, and that its presence could actually be causing the associated back pain to feel worse.
Therefore, having an annular tear MRI to help diagnose the condition and begin treatment is a good idea to help start treatment early.
Symptoms
An annular tear most commonly affects the spine (of the lower back, also called the lumbar spine). Minor or early forms of the condition may not cause any symptoms. But if the tear becomes larger or it’s caused more severe disc degeneration and leakage of the nucleus pulposus, it becomes a symptomatic annular tear that can lead to the following:
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Back pain that starts suddenly in a specific part of the back (most commonly low back pain as it tends to affect a lumbar disc rather than one higher up in the spine)
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Back pain that doesn’t get any better or feels worse when sitting, bending, twisting or lifting
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A burning or tingling sensation, muscle weakness or numbness in the back that may radiate out towards the arms, hands, buttocks, legs and feet
What Does an Annular Tear Look Like on MRI?
An annular tear MRI scan is considered the most reliable test used to diagnose an annular tear. MRI scans provide a detailed picture of the bones and soft tissues of the body. If an annular tear is present, it will show abnormalities in the lumbar region such as disruption to the annular fibres and disc protrusion (bulging) indicating an annular tear.
Diagnosing an Annular Tear
There are numerous steps to getting a diagnosis of an annular tear. If you’re experiencing low back pain or symptoms that are concerning you, make an appointment to see your GP, who can then refer you to a specialist for further tests including some or all of the following:
Patient History Evaluation
First off, your doctor will ask you some questions about your current overall health and wellbeing, previous medical history and whether or not you smoke and drink alcohol. They will then ask about your back pain symptoms and what makes them feel worse or better.
Physical Examination
Your GP or specialist doctor will ask you to lay on a bed while they feel around the area to assess your level of pain, muscle strength and mobility, and to discover where it might be coming from. They will also take your height and weight measurements.
Neurological Assessment
A neurological assessment can form part of your annular tear diagnosis. This is a type of physical examination to check your motor skills, balance, reflexes and coordination to check for anomalies that could be linked to your back pain.
X-Rays
You may also undergo an x-ray to look for any physical abnormalities in the bones of the spine, in particular in the alignment of the spine or for any degeneration in the vertebrae that could be causing your pain.
MRI
A magnetic resonance imaging (MRI) scan will allow your medical team to look for any abnormalities including a lumbar disc bulge and any disc herniation to help them confirm or rule out an annular fissure.
CT Scan with Discography
If necessary, you may also have a CT (computerised tomography) scan with discography. A CT scan with discography differs from a standard CT scan in that the discography part involves the use of a dye that’s injected into a blood vessel. This dye will then show up on the scan and reveal any tears or damage to the annulus fibrosus of any of the lumbar discs.
Myelogram
A myelogram may also be conducted alongside a CT scan, especially if you can’t have an MRI scan. Myelograms look for compressed, or pinched, nerves that can be caused by the nucleus pulposus leaking near to a nerve root.
Electromyography (EMG) or Nerve Conduction Studies
An electromyogram, or nerve conduction study, looks for injury to the nerve roots. It may be used to diagnose an annular tear by measuring how the muscles around the lumbar spine react to nerve signals. If there’s a different reaction than expected, it can indicate the presence of a pinched nerve.
Blood Tests
Blood tests are a routine part of any set of medical investigations. Therefore you may also have some blood tests to check your overall health such as cholesterol levels, liver and kidney function, levels of certain vitamins and minerals and for the presence of any infection or inflammation.
Differential Diagnosis
When undergoing an annular tear MRI scan and other tests to confirm or rule out the condition, your medical team may also look for signs of other conditions that may be causing your symptoms. These include:
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Sciatica
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Herniated disc
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Facet joint syndrome
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Degenerative disc disease
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Spinal stenosis
Causes of an Annular Tear
Like many conditions that affect the back, the main contributing factor to annular tears is age. The back is often under a lot of pressure as we stand, walk, twist and lift - even sitting down places pressure on the spine. As we age, the spinal discs experience a considerable level of wear and tear, potentially causing them to be more susceptible to experiencing an annular tear.
Other causes of annular fissures include:
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Being overweight or obese
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A job or lifestyle that involves lots of heavy lifting or bending
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Experiencing an accident or fall that causes injury to the back
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A sudden or unexpected movement such as an awkward twist or bending over too quickly
Prognosis and Treatment
Patients diagnosed with an annular fissure have a variety of treatment options; the right one will depend on your personal circumstances and the severity of your symptoms. Anti inflammatory medications and steroid injections can help to ease pain and physical therapy such as chiropractic treatment can help to improve mobility.
If these options don’t improve your symptoms, you may be eligible for minimally invasive surgical treatment. One option is laser treatment to seal off the annular tear to prevent it from getting worse and another is an endoscopic discectomy that uses keyhole surgery to remove any loose fragments of disc. For the most severe of cases, surgery to replace the affected disc or to fuse two discs together can provide long term relief.
Why an MRI Scan is a Good Option
An MRI scan doesn’t involve the use of x rays and therefore, exposure to radiation isn’t an issue. This makes an MRI scan a safer way of looking inside your body at the health of your spine to get to the root of your back pain symptoms.
How an MRI Scan Detects an Annular Tear
An MRI scan uses strong magnetic fields and radio waves to produce an image of the bones and soft tissues inside the body. Specifically, an annular fissure will show on an MRI scan as a brighter section of tissue, compared to the rest of the annulus fibrosus, helping your specialist definitively diagnose the presence of an annular tear that’s causing your symptoms.
Find an MRI Scan for an Annular Tear
If you’re experiencing back pain or you’re concerned about an annular tear, then having an MRI scan will give you peace of mind and the opportunity to start exploring your treatment options. Book a private MRI scan with us and start your journey towards a more comfortable and pain free back!
Having back pain can be distressing and affect your enjoyment of day to day life and your ability to work. But knowing what’s causing your pain can feel confusing and daunting. If you’re unsure if an annular tear MRI is right for you, make an appointment to see one of our expert private consultants to discover what tests and scans are the right options for you.
References
Mork, T. (2024, September 25). Annular Tears & Annular Fissures | Everything You Need To Know. Dr. Tony Mork, MD - Endoscopic Spine Specialist. https://drtonymork.com/back-pain/annular-tear/annular-tears/
Total Spine and Orthopedics. (2024, June 11). Annular tear - symptoms and treatments - Total spine and orthopedics. https://totalspineortho.com/spine-conditions/annular-tear/
Peng, B., Hao, J., Hou, S., Wu, W., Jiang, D., Fu, X., & Yang, Y. (2006). Possible pathogenesis of painful intervertebral disc degeneration. Spine, 31(5), 560–566. https://doi.org/10.1097/01.brs.0000201324.45537.46
Tenny, S., & Gillis, C. C. (2023, August 7). Annular disc tear. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459235/
