Lower back and leg pain

Bao Heng
Lumbar disc herniation

Lumbar spinal stenosis

 Lumbar disc herniation

Anatomy
Clinical features
Radiological exam
Differential diagnosis
Treatment
 Anatomy

 Intervertebral disc
1. Annulus fibrosus
2. Nucleus pulposus
3. End plate
 Anulus fibrosus

 Anulus fibrosus makes up peripheral

portion of disk structure
 Composed of fibrocartilage and type I
collagen

 Anulus is wider anteriorly than posteriorly

 Nucleus pulposus

 Nucleus pulposus consists of a network of

delicate collagenous fibers in a mucoprotein gel
 Nucleus has a high water content,apparently
the result of imbibition by the gel;
 It functions to resist compressive loads;
water content declines with advancing age
 Gradual loss of proteoglycan content explains
the loss of water w/ aging
 Disc pressure / failure

 Intradiscal pressure is higher when sitting

than when standing; - sitting-leaning
forward > sitting > standing > lying on side
> supine;
 Rotation combined w/ flexion are the worst
positions for disc injury;
 It is elevated by bending forward, bending
to side, lifting, coughing, sneezing, and
straining;
 Asymmetric & cyclic loading combined w/
lateral bend, compression, and flexion are
risk factors for disk herniation;
 Sciatic nerve

 Anterior branchs of L4,L5,S1-3

 L4 root

 •Foot inversion (tibialis anterior m.)

 •Patellar reflex

 •Medial aspect of foot sensation

 L5 root

 •Great toe extension (extensor hallicus

longus m.)
 •No reflex
 •Dorsum (top) of foot sensation
 S1 root

 •Foot eversion (peroneus longus m.)

 •Achilles tendon reflex

 •Lateral foot sensation

 Posterolateral disc herniation

Protruded disc usually

compresses next lower nerve as
that nerve crosses level of disc
in its path to its foramen
 Central (posterior) herniation

 In the lower lumbar segments, central

herniation may result in S1 radiculopathy

 Cauda equina syndrome

 Far lateral disc herniation

 Compress the nerve root above the level of the

herniation (hence a L4-L5 far lateral herniation
may result in a L4 radiculopathy)
 Occurs in 6-10% of all lumbar disc herniations;

 L4 nerve root is most often involved;

 Patient typically have intense radicular pain
(sciatic 25% and femoral 75% of the time)
Far lateral disc herniation
 Symptoms and signs

Low back pain with radiation of

severe pain down the back of the
leg to the ankle and foot.

Neurological signs such as motor

and sensory loss and occasionally
bladder involvement.
 Spasm of the spinal muscles with
tenderness over the lower lumbar
spine on the side of the lesion.
The muscular spasm may produce a
scoliosis.
 There may be a history of previous
episodes of back pain and sciatica
or of a previous injury.
 Protrusion of the L4/5
disc

 Protrusion of the L4/5 disc may cause L5

root pressure with pain radiating down the
leg to the dorsum of the foot.
 Numbness on the outer side of the calf and
medial two-thirds of the dorsum of the
foot
 Weakness of dorsiflexion, particularly
of the foot and toes.
 Protrusion of the
L5/S1

 The S1 nerve root is compressed

 Pain and numbness on the outer side of
the foot and under side of the heel.
 Weakness of both eversion and
antarflexion of the foot
 The ankle jerk is diminished or absent
Protrusion of the L3/4

Protrusion of the L3/4 disc may

cause pressure on the L4 nerve root
Numbness over the front of the knee
and leg
The knee jerk is diminished.
Weakness of the knee extensors.
 Central protrusion

 Central protrusion of a lower lumbar disc

can press on the cauda equina and lead to
urinary retention.

 On examination there is usually perianal

numbness and a patulous anus.
 Emergency decompression is essential to avoid
permanent damage to sphincter innervation.
 Cauda equina

 The spinal cord ends in the lumbar area and

continues through the vertebral canal as
spinal nerves. Because of its resemblance
to a horse's tail, the collection of these
nerves at the end of the spinal cord is
called the cauda equina. These nerves send
and receive messages to and from the
lower limbs and pelvic organs.
 Limitation of lateral flexion of the
lumbar spine to the same side will be
most marked with a protrusion lateral
to the nerve root
 while limitation of lateral flexion to
the opposite side will be most marked
with a protrusion medial to the nerve
root.
 Straight Leg Raise

 In a normal person, this can be done to

about 75 or 80 degrees of flexion at the
hip without sharp pain radiates down to
the leg.
 Well leg or cross leg sign: if there is a left
sided herniation, raising the right leg may
cause pain to shoot down the course of the
left sciatic nerve.
 Sciatic stretch test: this test is performed
after a straight leg raising test by lowering the
affecting leg a few degrees below
the point .
 Radiographs

 Traction spurs

 Disc space narrowing

CT
 MRI

 There is a 29% prevalence of disc

herniation in asymtomatic individuals
MRI
Differential diagnosis

 Secondary tumours and

multiple myeloma of the
lumbar spine which usually
cause vertebral destruction
with sparing of the discs.

 Fractures and infections

 Natural History

 Prognosis of disc herniation is generally

good regardless of treatment;

 Patients operated on for proven disc

herniations improved more rapidly than
patients treated non operatively;
 Natural History

 Within 4-5 years both operative and

non operative treatment groups will
generally have comprable neurologic
recovery; hence long term results
are similar w/ or w/o surgery;
 Of all patients who sustain acute
sciatica, less than 25% will require
surgery;
 Treatment

Nonoperative treatment

Pain relief is best achieved

by immobilizing the spine and
strengthening the back muscles
 Nonoperative treatment

 Bed rest
 Nonsteroidal anti-inflammatory
agents
 Active physical therapy
 Skin traction for sciatic irratation
 Epidural steroid injection
 Epidural abscess

Abscess compulsive position

 Male, 43 yrs , fever ,pain

 After Epidural steroid injection
 Surgery

 Opened surgery

 Minimally invasive surgery

 Indications for
operation

 Cauda equina lesions

(emergency decompression)
 Progressive or unresponsive
lesions with appreciable
neurological signs despite
conservative management.
 Complications

 Infections

 Recurrence

 Instability
 Postoperative discitis

Preoperative

postoperative
 Lumbar instability

 10 years after surgery

 Lumbar stenosis

 Spinal stensosis is a narrowing of the

spinal canal or neural foramina producing
root ischemia and neurogenic claudication

 Although degenerative spondylolisthesis

is common cause of stenosis, 10% of
adults > 65 yrs may have this finding &
many are asymptomatic;
 Clinical Findings

 Patients are usually 60 years or older;

 Unilateral or bilateral leg pain, w/ or
without back pain;
 Pain occurs when the patient is upright
and particularly when walking
 Typical symptom is leg pain, numbness,
and weakness developing after patient
walks a predictable distance; - patient
seeks relief by sitting, leaning forward to
"relieve pressure
 Phalen test

 With patient upright, bend the patient into

extension for a full minute
 This should accentuate the spinal stenosis;
 Positive test will produce a crescendo of leg
symptoms followed by rapid relief of these
symptoms when the patient flexes forward,
places his hands on examination
table, and places one foot on stool
 CT scan:

 Evaluate for lateral stenosis & central

stenosis

 Dural sac w/ AP diameter of < ten

millimeters is consistent w/ clinical
syndrome of lumbar stenosis;
 Surgical Treatment

 Decompression
 Laminae are minimally trimmed for
exposure;
 Includes widening of lateral recess;
 Removal of medial rim of facets
 Adult Degenerative
Spondylolisthesis

 Often occurs as a result of degenerative

disc disease and facet deficiency;
 It is often associated w/ intersegmental
instability and w/ central stenosis;
 Involves L4-L5 level four times more often
than the L5/S1 level;
 Often causes radiculopathy related to
nerve compression within the foramen (ie,
L4/L5 spondylithesis will cause a L4
radiculopathy)
 Dynamic radiographs

 Flexion-Extension X-rays
 Non Operative Treatment

 NSAIDS
 Epidural steroids
 Bracing
 Change of job type
 Surgery

 Decompression of the nerve roots

 Stabilization by posterolateral fusion