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 Welcome to the Back Pain section   Go to back pain page 



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Lower back pain and bladder dysfunction


Low back pain is one of the main reasons for a visit to a general practitioner. More than 95% of patients who have low back pain have a benign musculoskeletal pain syndrome; the pain is a manifestation of a more serious pathology in only 5%. Central disc prolapse causing cauda equina syndrome is only present in 2% of all cases of a herniated lumbar disc and in only 0.04% of all patients with low back pain.

Herniation of an intervertebral disc is generally the result of degeneration of the disc. The inner nucleus herniates through the ruptured outside (annulus fibrosus) of the disc. The herniated tissue causes compression of dorsal roots in the spinal canal, which can result in pain, changed reflexes, and sensory and motor loss. The level of the herniation relates to the symptoms (table). In most cases lumbar herniations are at the level of L4-L5 or L5-S1. Herniation of the intervertebral disc mainly affects men aged 40-50.

Nerve RootPainSensory deficitMotor deficitReflex deficit
L2Anterior medial thighUpper thighSlight quadriceps weakness; hip flexion; thigh adductionSlightly diminished suprapatellar
L3Anterior lateral thighLower thighQuadriceps weakness; knee extension; thigh adductionPatellar or suprapatellar
L4Posterolateral thigh, anterior tibiaMedial legKnee and foot extensionPatellar
L5Dorsum of footDorsum of footDorsiflexion of foot and toesHamstrings
S1-2Lateral footLateral footPlantar flexion of foot and toesAchilles
S3-5PerineumSaddleSphinctersBulbocavernosus; anal

The rare diagnosis of cauda equina syndrome secondary to central disc prolapse is made on suspicion. Most patients complain of unilateral or bilateral leg pain and numbness in the perineum or leg or both.The most sensitive (0.90) and specific (0.95) finding is urinary retention or, later, even incontinence.Saddle anaesthesia and decreased sphincter tone on rectal examination, with sensitivities of 0.75 and 0.6-0.8, make the diagnosis even more plausible.Lasègue’s straight leg test, which will cause pain by elongating the nerve root by passive flexion of the hip in a supine patient, is not very sensitive in this case. Onset can be gradual, as in this man, or sudden with acute trauma related sciatic pain and problems with vesicular control.Unlike most other back problems it may even be painless.

The man had a partial laminotomy, and discectomy at the level of L4-L5 was successfully performed six hours after initial admission. He was discharged after four days, and apart from minimal sensory loss of his left foot he had no complaints at three months’ follow up.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

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