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Herniated Disk

Lumbosacral radiculopathy. This is a 26 year old female presents with a six month history of back and left lower extremity pain herniated disk, sciatica, siatica. The pain is most severe in the buttock region and it is deep and has a burning quality. The pain radiates to the calf, she represents a pharmaceutical company and spends many hours driving a car. She has to frequently load and unload her car with product samples. She also complains of numbness involving the left lateral foot and leg. Climbing stairs has become very difficult for her, but she doesn’t know the reason. On physical exam, she has decreased sensation on the lateral aspect of her foot, her left ankle jerk is diminished. She can walk on her left heel but cannot perform five toe raises on the left side. She squats but on return to stand she has some difficulty and she shifts her weight to the right. Now basically that single leg heel lift.

Absolute indication for surgery, you need to know these, this is when you call your local surgeon up and say I need your help. Bowel or bladder incontinence, this is a surgical emergency. Saddle numbness, also a surgical emergency and progressive weakness, where, this person had weakness of her foot and now it is in the thigh, so we are having a lot of problems and we could have a cauda equina syndrome. That is what we are worried about. Relative indications for surgery include continued symptoms despite adequate conservative management.

Nerves are injured mechanically, metabolically through infection and through inflammation. Now mechanically it’s the space where the nerves travel is too small, very simple. Examples are carpal tunnel syndrome through the transverse carpal ligament and lumbosacral radiculopathies from herniated nucleus pulposus. Metabolically the primary metabolic disease breaks the nerve down at the axon or the myelin level, example as being diabetes, obviously a very common malady and uremia from chronic renal insufficiency. Infection is by the nerves myelin and/or axon being broken down by the primary infectious process or as a secondary reaction to the infection.

Our focus today is going to be on the mechanical causes of nerve injuries, and we are going to talk about carpal tunnel syndrome, lumbosacral radiculopathies, peroneal neuropathies at the fibular head, cervical radiculopathies and ulnaropathy at the elbow. Before we do that I am going to talk about three classifications of nerve injuries. We are going to start talking through neuropraxia. Now neuropraxia, you can see it is a local myelin injury and if you remember that slide that looked at the nerve itself, and it had myelin on the outside and the axon on the inside.