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New Treatments for Herniated Lumbar Disc

Symptoms of a herniated lumbar disc may often be difficult to distinguish from those of other spinal disorders or simple back strain.

Clinical evaluation

The most common levels for a herniated disc are L4-5 and L5-S1. The onset of symptoms is characterized by a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, to below the knee. Pain is generally superficial and localized, and is often associated with numbness or tingling. In more advanced cases, motor deficit, diminished reflexes or weakness may occur in herniated disc and sciatica.

If a disc herniation is responsible for the back pain, the patient can usually recall the time of onset and contributing factors, whereas if the pain is of a gradual onset, other degenerative diseases are more probable than disc herniation.

Rheumatoid arthritis often begins in the appendicular skeleton before progressing to the spine. Inflammatory arthritides, such as ankylosing spondylitis, cause generalized pain and stiffness that are worse in the morning and relieved somewhat throughout the day.

"Red Flags" for Potentially Serious Conditions

Possible condition

Findings from the medical history

Fracture

Major trauma (motor vehicle accident, fall from height)

Minor trauma or strenuous lifting in an older or osteoporotic patient

Tumor or infection

Age >50 years or <20 years

History of cancer

Constitutional symptoms (fever, chills, unexplained weight loss)

Recent bacterial infection

Intravenous drug use

Immunosuppression (corticosteroid use, transplant recipient, HIV infection)

Pain worse at night or in the supine position

Cauda equina syndrome

Saddle anesthesia

Recent onset of bladder dysfunction

Severe or progressive neurologic deficit in lower extremity

Cauda equina syndrome. Only the relatively uncommon central disc herniation provokes low back pain and saddle pain in the S1 and S2 distributions. A central herniated disc may also compress nerve roots of the cauda equina, resulting in Only the relatively uncommon central disc herniation provokes low back pain and saddle pain in the S1 and S2 distributions. A central herniated disc may also compress nerve roots of the cauda equina.

Low back strain should be differentiated from central herniated disc. Pain caused by low back strain is exacerbated during standing and twisting motions, whereas pain caused by central disc herniation is should be differentiated from central herniated disc. Pain caused by low back strain is exacerbated during standing and twisting motions, whereas pain caused by central disc herniation.

Physical and neurologic examination of the lumbar spine

External manifestations of pain, including an abnormal stance, should be noted. The patient's posture and gait should be examined for sciatic list, which is indicative of disc herniation. The, including an abnormal stance, should be noted. The patient's posture and gait should be examined for sciatic list, which is indicative of disc herniation.

Range of motion should be evaluated. Pain during lumbar flexion suggests should be evaluated. Pain during lumbar flexion.

Motor, sensory and reflex function should be assessed to determine the should be assessed.

Specific movements and positions that reproduce the symptoms should be documented. The upper lumbar region (L1, L2 and L3) controls the iliopsoas muscles, which can be evaluated by testing resistance to hip flexion. While seated, the patient should attempt to raise each thigh while the physician's hands are placed on the leg to create resistance. Pain and weakness are indicative of upper lumbar nerve root involvement. The L2, L3 and L4 nerve roots control the quadriceps muscle, which can be evaluated by manually trying to flex the actively extended knee. The L4 nerve root also controls the tibialis anterior muscle, which can be tested by heel walking.

The L5 nerve root controls the extensor hallucis longus, which can be tested with the patient seated and moving both great toes in a dorsiflexed position against resistance. The L5 nerve root also innervates the hip abductors, which are evaluated by the Trendelenburg test.

Cauda equina syndrome can be identified by unexpected laxity of the anal sphincter, perianal or can be identified by unexpected laxity of the anal sphincter.

Nerve root tension signs are evaluated with the straight-leg raising test in the supine position. The physician raises the patient's legs to 90 degrees. Normally, this position results in are evaluated with the straight-leg raising test in the supine position. The physician raises the patient's legs to 90 degrees.

The most common sites for a herniated lumbar disc are L4-5 and L5-S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee. are L4-5 and L5-S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee.

A crossed straight-leg raising test may suggest nerve root compression. In this test, straight-leg raising of the contralateral limb reproduces more specific but less intense pain on the affected side. In may suggest nerve root compression. In this test, straight-leg raising of the contralateral limb reproduces more specific but less intense pain on the affected side.

Nonorganic physical signs ( Waddell signs) may identify patients with pain of a psychologic or socioeconomic basis. These signs include superficial tenderness, positive results on simulation tests (ie, maneuvers that appear to the patient to be a test but actually are not), distraction tests that may identify patients with pain of a psychologic or socioeconomic basis.

 

Location of Pain and Motor Deficits in Association with Nerve Root Involvement

Disc level

Location of pain

Motor deficit

T12-L1

Pain in inguinal region and medial thigh

None

L1-2

Pain in anterior and medial aspect of upper thigh

Slight weakness in quadriceps; slightly diminished suprapatellar reflex

L2-3

Pain in anterolateral thigh

Weakened quadriceps; diminished patellar or suprapatellar reflex

L3-4

Pain in posterolateral thigh and anterior tibial area

Weakened quadriceps; diminished patellar reflex

L4-5

Pain in dorsum of foot

Extensor weakness of big toe and foot

L5-S1

Pain in lateral aspect of foot

Diminished or absent Achilles reflex

Treatment of herniated disc