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. This test requires the
Cauda equina syndrome can be identified by unexpected laxity of the anal sphincter, perianal or
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
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.
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
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
|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|
Imaging of the herniated disc
The major finding on plain radiographs of patients with a herniated disc is decreased disc height. Radiographs have limited diagnostic value for herniated disc because degenerative changes are
The gold standard for herniated disc is magnetic resonance imaging (MRI). MRI has the ability to demonstrate disc damage, including anular tears and edema. MRI can reveal bulging and
Treatment of herniated disc
The majority of patients experience resolution of their symptoms regardless of the treatment method. About 70 percent of patients have a marked reduction in leg pain within four weeks of the onset of
Bed rest in excess of two days is not associated with a better outcome and continuing to perform
Naproxen sodium (Anaprox) 550 mg, followed by 275 mg PO tid-qid prn.
Trigger point injections can provide extended relief for localized pain sources. An injection of 1 to 2 mL of 1 percent lidocaine (Xylocaine) without epinephrine is
Indications for herniated disc surgery. While most patients with a herniated disc may be