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.
Lumbar Disc Herniation
Acute Lumbar Disc Herniation
Brain and Spinal Cord
Motor pathway: Pathway from the brain motor cortex to muscle
Sensory pathway from organs to the brain
Spine Reflex Arc
Involuntary reflex arc pathway
Bone anatomy
Spine & relationship to hip joint
Lumbar Spine
Anatomy
Disc Anatomy
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
Acute disc herniation with underlying spinal stenosis
Examination
T-L Spine
T-L Spine:
Inspect
Palpate
L-spine Range of Motion (ROM)
Flexion & extension
Bending forward & backwards
Flexion and extension with pivoting posterior through facet joints
Flexion
Extension
Lateral flexion
Rotation
Reflexes
Lower limb reflexes:
- Assess bilateral upper and lower limbs
- Look for muscle wasting
Patellar reflex test
Sensation Examination
Sensory Cutaneous Nerves
Dermatome
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
Clinical test:
Resisted hip flexion (hip flexor muscles)
L3
Quadriceps function
Clinical test: Resisted lower leg extension
L4
Ankle dorsiflexion
Ankle dorsiflexion against resistance
Clinical test:
Resisted ankle dorsiflexion
L5
Big toe extension
Big toe extension
Clinical test:
Resisted big toe extension (Extensor Hallucis Longus muscle)
S1
Ankle plantarflexion
Calf raises
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
Kernig test:
- Radicular pain reproduced by neck flexion, hip flexion and leg extension
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
Management
Acute disc herniation
- Stretching
- Core strength
- Progressive abdominal and back strengthening
- Correct any biomechanical deficit
- Address Sports specific techniques where relevant
Download ASSIC performance fingerprint or ASSIC strength & conditioning aps for back rehabilitation guideline routines or create own routine under professional guidance
Surgery: Acute disc herniation
Surgery:
- Cauda equina syndrome
- Neurologic deficit
- Pain non-responsive to conservative management
Surgery
References
- 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.
- Management of lumbar conditions in the elite athlete. WK Hsu, TJ Jenkins. J Am Acad Orthop Surg. 2017 Jul;25(7): 489-498.
- 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.
