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Smoking
Occupations involving extended periods of sitting for example office work or taxi driving
Trauma
Age - "wear and tear" of the disc or "drying out" of the disc
medical
for too
long!!!]
The disc can herniate at any level in the spine, but it must commonly occurs in the lumbar
region, specifically at L4/L5 and L5/S1.
Clinical Features
1. The patient is typically a young and fit adult presenting with sudden onset back pain whilst
lifting or stooping.
2. They are unable to straighten up due to severe pain.
3. From the onset of the injury, the patient may present with:
Backache
Muscle weakness
Urinary retention
Backache and sciatica persists after the injury and is typically made worse by coughing or
straining.
Observation
Sciatic Scoliosis - the patient may stand with a slight list to
one side, increased during forward flexion
Range of back movements severely limited in all planes
Palpation
Special Tests
Straight Leg Raise (SLR) - Tests for herination at L4/L5
or L5/S1 discs.
This test is performed with the patient lying flat on their
backs on the examination couch or bed.
1.
Raise one leg, keeping the knee joint completely straight, until pain is felt in the
buttock, thigh or calf.
2.
Note the angle at which pain occurs. In normal circumstances pain is felt above
80-90 degrees. The test is positive when pain is felt between 30-70 degrees.
3.
Flexing the knee at this point will relieve buttock pain. Pressing on the popliteal
nerve will reproduce the pain.
4.
Straighten the leg again and then lower the leg to below the angle where pain is
felt.
Dorsiflex the foot. If the pain is due to sciatica, this should reproduce the
pain.
Patients with lumbar herniation will have a limited SLR and it will be painful on
the affected side.
'Crossed Sciatic Tension' - Raising the unaffected leg may cause sciatic tension
on the painful side. This may be observed but is not a common finding.
Femoral Stretch Test - May be positive if nerve root of L3/4 is affected. This test is
performed with the patient lying prone on the examination couch.
1. Flex the knee to 90 degrees
2. Extend the hip
3. Pain is felt in the anterior thigh.
Neurological Examination
At the corresponding level of prolapse, you may find:
Muscle weakness (later wasting)
Diminished reflexes
Sensory loss
L5 impairment
weakness of big toe extension
weakness of knee flexion
sensory loss on the outer side of the foot
sensory loss on the dorsum of the foot
S1 impairment
weak plantar flexion
weak eversion of the foot
a depressed ankle jerk reflex
Sensory loss along the lateral border of the foot.
Imaging
MRI is the most valuable method of imaging as it confirms the presence, level,
size and extension of the disc herniation.
An X-ray must be performed to rule out any bone pathology.
Differential Diagnosis
1.
Inflammatory disorders:
Ankylosing Spondylitis causes severe and
more generalised stiffness and typical xray changes.
Tuberculosis of the spine (Potts Spine)
will produce a raised ESR.
2.
3.
Nerve tumours - may cause sciatica but pain is continuous. CT or MRI may
delineate the lesions
Treatment
The majority of herniated discs will heal themselves within 6-8 weeks and do not
require surgery.
Management problems arise if pain lasts longer than 8 weeks.
Non-Surgical or conservative management methods are usually tried first.
These include:
Physiotherapy
Heat therapy
Analgesics
Anti-inflammatory drugs
Weight loss
Smoking cessation
Surgical management
The indications for surgical management are:
1.
Cauda equina syndrome which does not clear up within 6 hours of starting bedrest and traction (Medical emergency)
2.
Persistent pain and severely limited straight leg raising after 2 weeks of
conservative management
3.
4.
Rehabilitation
Rehabilitation is essential for patients once they have recovered from acute disc
rupture or disc removal.
The patient is taught isometric exercises in order to reduce the strain on their
back.
Light work in resumed after 1 month and heavy work after 3 months.
If the patient fails to recover fully, heavy lifting should be avoided all together.