• +27 (0)21 879 4264
  • info@assicfitness.com
  • My account
  • Cart

  • Home
  • Applications
    • Resting Heart Rate
    • Recovery Heart Rate
    • Fitness
    • Performance Fingerprint
    • Strength and Conditioning
  • Health Professionals
    • Find your Professional
    • Book a Professional
  • Education
    • Know your Body
      • Body profile
      • Cardiac
      • Exercise/Rehab Routines
      • Fitness
      • Fluid Balance
      • Muscle
      • Bone/Tendon/Joint
      • My Surgery
      • Yoga
      • Nutrition
    • Blog
      • Articles
      • Monthly Routines
      • News and Opinion Pieces
    • COVID-19
      • What You Need to Know
      • Overview of COVID-19
      • COVID-19 Map
    • How to Use the Apps
      • Performance Fingerprint
      • COVID-19 Vitals
      • Connecting Professionals
    • Biomarkers
      • COVID-19
      • Infection/Inflammation
      • Endurance
      • Hydration
      • Performance Fatigue
      • Metabolism
      • Muscle Cramps
      • Nutrition
    • Medical
      • Hip
      • Knee
      • Ankle/Foot
      • Shoulder
      • Elbow
      • Wrist/Hand
      • Back
  • Health Calculators
  • About
    • Contributors
      • Become a Contributor
    • Partners
      • Lancet Laboratories
    • Professionals
    • Press
    • Professional Dual View Access Application
  • Contact
✕

Lumbar Disc Herniation

Categories
  • Education
  • Joint/Tendon
Tags
  • back injury
Spine Examination

Acute Lumbar Disc Herniation

Acute lumbar disc herniation is common and presents with lower backache ± radicular pain radiating down the buttock or leg. Strain across the lumbar disc produces an annular ligament tear with progression to an acute disc herniation ± nerve root compresion. The most common area is the L4/5 or L5/S1 level. Most often the management is non-operative with treatment that include analgesia and rehabilitation.

Brain and Spinal Cord

brain-relay
Brain and Spinal Cord

Motor pathway: Pathway from the brain motor cortex to muscle

Sensory pathway from organs to the brain

Sensory pathway from organs to the brain

Spine Reflex Arc

Involuntary reflex arc pathway

Involuntary reflex arc pathway

Spine

Bone anatomy
Spine & relationship to hip joint

Spine & relationship to hip joint

Lumbar Spine

Lumbar spine
Lateral and Superior View

Anatomy

Lumbar vertebrae
Posterior View
Vertebra lumbalis: Anterior View

Disc Anatomy

Disc anatomy: Acute Lumbar Disc
Disc anatomy: Acute Lumbar Disc

Disc Herniation

Acute disc herniation

Acute disc herniation with nerve root compression. Protrusion refers to an eccentric bulge with an intact annulus while extrusion refers to herniated disc protruding through the annulus but continuous with the central disc. The herniated disc material may be completely separated from the central disc and then it is referred to as sequestered.  Herniation is usually posterolateral (paracentral) as indicated. Other locations include central, foraminal or axillary. Most common disc space involved in the lumbar area is the L5/S1 or L5/S1 area.

Spinal Stenosis

Spinal stenosis
Spinal stenosis with an acute disc herniation

Acute disc herniation with underlying spinal stenosis

Examination

T-L Spine

T-L Spine
T-L Spine:

Inspect

Palpate

L-spine Range of Motion (ROM)

Flexion & extension

Bending forward & backwards

Facet Joints

Flexion and extension with pivoting posterior through facet joints

L-spine ROM: Flexion

Flexion

L-spine ROM: Extension

Extension

L-spine ROM: Lateral flexion

Lateral flexion

L-spine ROM: Rotation

Rotation

Reflexes

Lower limb reflexes:

  • Assess bilateral upper and lower limbs
  • Look for muscle wasting
Patellar reflex test

Patellar reflex test

Sensation Examination

Sensory Cutaneous Nerves

Sensory cutaneous nerves
Sensory cutaneous nerves

Dermatome

Dermatome assessment
Dermatome assessment

Motor Examination

Muscle power grading

Examine the muscle power of each area suppled by the specific nerve and grade the muscle power.

Grade Description
0 No muscle contraction
1 Trace contraction by palpation while the muscle is being contracted
2 Muscle movement but without gravity
3 Muscle movement against gravity but not against resistance
4 Muscle movement against some resistance
5 Muscle against resistance, normal muscle strength

L1/2
Hip flexion

Hip flexion

Hip flexion

Resisted hip flexion (hip flexor muscles)

Clinical test:

Resisted hip flexion (hip flexor muscles)

L3
Quadriceps function

Quadriceps
Quadriceps strengthening using body weight
Quadriceps strengthening with resistance band
Closed chain Quadriceps
Resisted lower leg extension

Clinical test: Resisted lower leg extension

L4
Ankle dorsiflexion

Ankle dorsiflexion against resistance

Ankle dorsiflexion against resistance

Clinical test:

Resisted ankle dorsiflexion

L5
Big toe extension

Toe range of motion

Big toe extension

Resisted big toe extension (Extensor Hallucis Longus muscle)

Clinical test:

Resisted big toe extension (Extensor Hallucis Longus muscle)

S1
Ankle plantarflexion

Squat Into Calf Raise

Calf raises

Calf muscle and Achilles tendon Anatomy

Clinical test:

Resisted foot plantarflexion

Symptoms

  • Acute axial pain
  • Neurological symptoms of radiculopathy: Radiating pain along the nerve distribution with pain aggravated by sitting, coughing or valsalva
  • Weakness in the related nerve distribution
  • If spinal cord compression then upper motor neuron (UMN) symptoms and signs
  • Cauda equina syndrome: bilateral leg pain with involvement of bowel and bladder with saddle anesthesia

Clinical Examination

  • Sensory changes in the nerve distribution
  • Motor weakness by the nerve root being compressed
  • Assess Upper motor neuron (UMN) signs in lower limb for spinal cord compression
  • Examine lower limb reflexes
  • Assess bowel and bladder function

Provocative Tests

Straight leg raise test:

  • Tension sign for L5/S1 nerve root
  • Radicular pain reproduced with hip flexion and ankle dorsiflexion

Contralateral straight leg raise test:

  • Reproducible radicular signs performing same straight leg raise test on opposite side

Lasegue sign (test):

  • Straight leg raise test aggravated by dorsiflexing ankle while performing test

Bowstring sign:

  • Straight leg raise test aggravated by compressing popliteal fossa
Provocative tests of acute lumbar

Kernig test:

  • Radicular pain reproduced by neck flexion, hip flexion and leg extension
Kernig test

Urgent Emergency Management (Red flags)

  • Sensations changes in multiples nerve distribution
  • Motor weakness by multiple nerve root distribution
  • Spinal cord compression with UMN signs
  • Bowel and bladder involvement (multiple roots affected with cauda equina syndrome)

Investigations

X-ray spine

  • Loss of lordosis with disc space narrowing

MRI

  • Gold standard to assess acute disc prolapse and assess other associated conditional conditions and exclude the differential diagnostic diseases

Rehabilitation Principles

Conservative:

Indication: Acute pain without nerve compression

Majority of cases will respond to conservative treatment

  • Analgesia: NSAIDS
  • Muscle relaxants
  • Rehabilitation
  • Selective nerve root steroid injections: epidural and selective nerve blocks
Epidural spine injection

Epidural spine injection

Management

Acute disc herniation

  • Stretching
  • Core strength
  • Progressive abdominal and back strengthening
  • Correct any biomechanical deficit
  • Address Sports specific techniques where relevant
Stretching
Core strength
Progressive abdominal and back strengthening
Correct any biomechanical deficit

Download ASSIC performance fingerprint or ASSIC strength & conditioning aps for back rehabilitation guideline routines or create own routine under professional guidance

apple app store  google play store

Surgery: Acute disc herniation

Surgery:

  • Cauda equina syndrome
  • Neurologic deficit
  • Pain non-responsive to conservative management

Surgery

Surgery
Disc Surgery

References

  1. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. DA Van der Windt, E Simons, II Riphagen, C Ammendolia, AP Verhagen, M Laslett, W Devillé, RA Deyo, LM Bouter, HC de Vet, B Aertgeerts. Cochrane Database Syst Rev. 2010 Feb 17;(2): CD007431.
  2. Management of lumbar conditions in the elite athlete. WK Hsu, TJ Jenkins. J Am Acad Orthop Surg. 2017 Jul;25(7): 489-498.
  3. Epidural steroid injection for lumbar disc herniation in NFL athletes. AJ Krych, D Richman, M Drakos, L Weiss, R Barnes, F Cammisa, RF Warren. Med Sci Sports Exerc. 2012 Feb;44(2): 193-8.

Related posts

Shoulder
May 20, 2022

Thoracic Outlet Syndrome


Read more
Hand
May 13, 2022

Hand/Wrist Examination


Read more
Elbow
May 12, 2022

Elbow Examination


Read more
MRI Technique
May 10, 2022

Elbow MRI


Read more
assic fitness and health white logo

ASSIC is a pioneering technology based Sports Science Company designing tools to assist in personal fitness management for individuals and professional athletes.

Education

  • Home
  • Applications
  • Health Professionals
  • Education
  • Health Calculators
  • About
  • Contact

Our Applications

  • Resting Heart Rate
  • Recovery Heart Rate
  • Fitness
  • Strength and Conditioning
  • Performance Fingerprint
  • Medical Examination

Download our Applications

apple app store
google play store
© 2022 ASSIC Medical (PTY) Ltd. All Rights Reserved. Created and Hosted by: Lava Lamp Lab
0

R0.00

  • My account
  • Cart
✕

Login

Lost your password?

Create an account?

Change Location
Find awesome listings near you!