How do you treat degenerative disc disease PLID (Prolapse lumber intervertebral disc) is one of the most common vertebral column diseases of elderly people leading to back pain, radicular pain, and subsequently neurological deficit due to nerve root compression. It is a common condition that frequently affects the spine in young and middle-aged patients.1,5,11 The lumbar intervertebral disc is a complex structure composed of collagen, proteoglycans, and sparse fibrochondrocytic cells that serve to dissipate forces exerted on the spine. As part of the normal aging process, the disc fibrochondrocytes can undergo senescence, and proteoglycan production diminishes. This leads to a loss of hydration and disc collapse, which increases strain on the fibers of the annulus fibrosus surrounding the disc. Tears and fissures in the annulus can result, facilitating a herniation of disc material, should sufficient forces be placed on the disc. Alternatively, a large biomechanical force placed on a healthy, normal disc may lead to extrusion of disc material in the setting of catastrophic failure of the annular fibers.[Rx]
PLID (Prolapse lumber intervertebral disc), also known as a slipped disc, is a medical condiervertibral disction affecting the spine in which a tear in the outer, fibrous ring of an intervertebral disallows the soft, central portion to bulge out beyond the damaged outer rings. Rarely bowel or bladder control is lost, and if this occurs, seek medical attention at once.
- A common cause of lower back and leg pain is a lumbar ruptured disc or herniated disc. Symptoms of a herniated disc may include dull or sharp pain, muscle spasm or cramping, sciatica, and leg weakness or loss of leg function. Sneezing, coughing, or bending usually intensify the pain.
- Sciatica is a symptom frequently associated with a lumbar herniated disc. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot. Usually, one side (left or right) is affected.
Anatomy of PLID
First, a brief overview of spinal anatomy so that you can better understand how a lumbar herniated disc can cause lower back pain and leg pain.
In between each of the 5 lumbar vertebrae (bones) is a disc—a tough fibrous shock-absorbing pad. Endplates line the ends of each vertebra and help hold individual discs in place. Every disc has a tire-like outer band (annulus fibrosus) that encases a gel-like substance (nucleus pulposus).
Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape. This is called a herniated nucleus pulposus or herniated disc, although you may have also heard it called a ruptured disc or a bulging disc.
When a disc herniates, it can press on the spinal cord or spinal nerves. All along your spine, nerves are branching off from the spinal cord and traveling to various parts of your body (to help you feel and move). The nerves pass through small passageways between the vertebrae and discs, so if a herniated disc presses into that passageway, it can compress (or “pinch”) the nerve. That can lead to the pain associated with herniated discs.
(In the illustration below, you can see a close-up look at a herniated disc pressing on a spinal nerve.)
This article on lumbar herniated discs will cover the symptoms, causes, and (most importantly) treatments.
Anatomy of Spine
Complete intervertebral disc anatomy and biomechanics
- composed of type I collagen, water, and proteoglycans
- characterized by extensibility and tensile strength
- high collagen / low proteoglycan ratio (low % dry weight of proteoglycans)
- composed of type II collagen, water, and proteoglycans
- characterized by compressibility
- low collagen / high proteoglycan ratio (high % dry weight of proteoglycans)
- proteoglycans interact with water and resist compression
- a hydrated gel due to high polysaccharide content and high water content (88%)
Nerve root anatomy of PLID
The key difference between the cervical and lumbar spine is
pedicle/nerve root mismatch
- cervical spine C6 nerve root travels under C5 pedicle (mismatch)
- lumbar spine L5 nerve root travels under L5 pedicle (match)
- extra C8 nerve root (no C8 pedicle) allows transition
horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
- because of vertical anatomy of the lumbar nerve root, a paracentral and foraminal disc will affect different nerve roots
- because of horizontal anatomy of the cervical nerve root, a central and foraminal disc will affect the same nerve root
- often associated with back pain only
- may present with cauda equina syndrome which is a surgical emergency
- most common (90-95%)
- PLL is weakest here
- affects the traversing/descending/lower nerve root
- at L4/5 affects L5 nerve root
Foraminal (far lateral, extraforaminal)
- less common (5-10%)
- affects exiting/upper nerve root
- at L4/5 affects L4 nerve root
- can affect both exiting and descending nerve roots
- protrusion > eccentric bulging with an intact annulus
- extrusion > disc material herniates through annulus but remains continuous with disc space
- sequestered fragment (free)
- disc material herniates through the annulus and is no longer continuous with disc space
- Axial back pain (low back pain)
- this may be discogenic or mechanical in nature
Radicular pain (buttock and leg pain)
- often worse with sitting, improves with standing
- symptoms worsened by coughing, Valsalva, sneezing
Cauda equina syndrome (present in 1-10%)
- bilateral leg pain
- LE weakness
- saddle anesthesia
- bowel/bladder symptoms
- see lower extremity neuro exam
- motor exam
- ankle dorsiflexion (L4 or L5)
- test by having the patient walk on heels
- EHL weakness (L5)
- manual testing
- hip abduction weakness (L5)
- have the patient lie on the side on the exam table and abduct leg against resistance
- ankle plantar flexion (S1)
- have the patient do 10 single leg toes stand
Types of PLID
According to the position of spine disc herniation are 3 types
Herniation may develop suddenly or gradually over weeks or months. The 4 stages to a herniated disc are
- Disc Degeneration or Bulsing Disc – Chemical changes associated with aging causes discs to weaken, but without a herniation.
- Prolapse – The form or position of the disc changes with some slight impingement into the spinal canal and/or spinal nerves. This stage is also called a bulging disc or a protruding disc.
- Extrusion – The gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
- Sequestration or Sequestered Disc – The nucleus pulposus breaks through the annulus fibrosus and can then go outside the intervertebral disc.
Causes of PLID
- Piriformis syndrome – This develops when the piriformis muscle, a small muscle that lies deep in the buttocks, becomes tight or spasms, which can put pressure on and irritate the sciatic nerve & causes PLID.
- Spinal stenosis – This condition results from narrowing of the spinal canal with pressure on the nerves.
- Spondylolisthesis – This is a slippage of one vertebra so that it is out of line with the one above it, narrowing the opening through which the nerve exit
- Cauda equina syndrome –A rare, but serious condition that affects the nerves in the lower part of the spinal cord; it requires immediate medical attention. Cauda equina syndrome may permanently damage the nervous system and even lead to paralysis.
- Bony growths (osteophytes) – Bone spurs or osteophytes are bony outgrowths on the edges of joints. Bone spurs form where cartilage is worn away (for example in arthritis) and bone is rubbing on bone. In an effort to protect the body, new bone forms on the edge of joints. This is called a bone spur. Bone spurs are not painful in themselves, but unfortunately, the bone spurs can rub on nearby bone or nerves, causing problems. In the spine, bone spurs can intrude into space normally reserved for the nerves, thus causing sciatica.
- Sudden injury or accident – Some unexpected traumatic events, such as a car accident, can lead to sciatica. Injuries sustained and new scar tissue can place stress on the sciatic nerve.
- Pregnancy – During pregnancy, pain in the back of the thighs spurred by shifts in the pelvic region can be misdiagnosed as sciatica. However, there are situations in which the sciatic nerve is actually being pressed as a result of these changes. Speak to your doctor if you think you are suffering from sciatica or pelvic groin pain.
- Tumors within the spine may compress the root of the sciatic nerve.
- Infection within the spine.
- Injury within the spine.
Associate causes of PLID
- Spinal lesions and tumors
- Spinal infections or inflammation
- Lumbar spinal stenosis
- Violent injuries to the lower back (gunshots, falls, auto accidents)
- Birth abnormalities
- Spinal arteriovenous malformations (AVMs)
- Spinal hemorrhages (subarachnoid, subdural, epidural)
- Postoperative lumbar spine surgery complications
- Spinal anesthesia
- lumbar disc herniation (most common, especially at L4/5 and L5/S1)
- lumbar spinal canal stenosis
- Tarlov cysts
- facet joint cysts
- Traumatic events leading to fracture or partial dislocation (subluxation) of the low back (lumbar spine) result in compression of the sciatic nerve.
- Spinal fracture or dislocation
- Epidural hematoma (may also be spontaneous, post-operative, post-procedural or post-manipulation)
- A collection of blood surrounding the nerves following trauma (epidural hematoma) in the low back area can lead to compression of sciatica.
- Penetrating trauma (gunshot or stab wounds) can cause damage or compression of the sciatic nerve.
- A rare complication of spinal manipulation is partial dislocation (subluxation) of the low back (lumbar spine) that can cause sciatica syndrome.
- Most disk herniations will improve on their own (are self-limiting) and respond well to conservative treatment, including anti-inflammatory medications, physical therapy, and short periods of rest (one to two days).
- Sciatica syndrome can result from a herniated lumbar disk.
- Of lumbar disk herniations, most occur either at the vertebral levels L4-L5 or L5-S1.
- Seventy percent of cases of herniated disks leading to sciatica syndrome occur in people with a history of chronic low back pain, and some develop sciatica syndrome as the first symptom of lumbar disk herniation.
- Males in their 30s and 40s are most prone to cauda equina syndrome caused by disk herniation.
- Most cases of sciatica syndrome caused by disk herniation involve large particles of disk material that have completely separated from the normal disk and compress the nerves (extruded disk herniations). In most cases, the disk material takes up at least one-third of the canal diameter.
- Spinal stenosis is any narrowing of the normal front to back distance (diameter) of the spinal canal.
- Narrowing of the spinal canal can be caused by a developmental abnormality or degenerative process.
- The abnormal forward slip of one vertebral body on another is called spondylolisthesis. Severe cases can cause a narrowing of the spinal canal and lead to sciatica syndrome
Sciatica syndrome can be caused by isolated tumors (primary neoplasms) or from tumors that have spread to the spine from other parts of the body (metastatic spinal neoplasms). Metastatic spine tumors are most commonly from the prostate or lung in males and from the lung and breast in females.
- Malignant – lymphoma, metastases, primary CNS malignancies(e.g. ependymoma, schwannoma, neurofibroma)
- The most common initial symptom of people with cauda equina syndrome caused by a tumor (spinal neoplasm) is severe low back and leg pain.
- Later findings include lower extremity weakness.
- Loss of feeling in the legs (sensory loss) and loss of bowel or bladder control (sphincter dysfunction) are also common.
- Both acute and chronic form may be seen in long-standing ankylosing spondylitis (2nd-5th decades; average 35 years)
- Long-lasting inflammatory conditions of the spine, including Paget disease and ankylosing spondylitis, can cause a narrowing of the spinal canal and lead to sciatica syndrome.
- Infections in the spinal canal (spinal epidural abscess) can cause deformity of the nerve roots and spinal column.
- Symptoms generally include severe back pain and rapidly worsening muscle weakness.
- Infective – epidural abscess, tuberculosis (Pott disease)
Accidental Medical Causes (Iatrogenic Causes)
- Poorly positioned screws placed in the spine can compress and injure nerves and cause sciatica syndrome.
- Continuous spinal anesthesia has been linked to cases of sciatica syndrome.
- Lumbar puncture (spinal tap) can cause a collection of blood in the spinal canal (spontaneous spinal epidural hematoma) in patients receiving medication to thin the blood (anticoagulation therapy). This collection of blood can compress the nerves and cause sciatica syndrome.
- Aortic dissection
- Arteriovenous malformation
Symptoms of PLID
Weakness in the Legs – The weakness is often times asymmetric.
Loss of Sensation – Those affected may experience numbness or tingling in their perineum
Loss of Reflexes – A person’s knee and ankle reflexes might be diminished, along with anal and bulbocavernosus abilities.
Sensory Loss – Sensory loss may range from, ‘pins and needles,‘ to complete numbness. It might affect a person’s bowel, bladder and genitalia Bladder, Bowel and
Associate clinical feature is..
- Severe back pain
- Saddle anesthesia i.e., anesthesia or paraesthesia involving S3 to S5 dermatomes, including the perineum, external genitalia, and anus; or more descriptively, numbness or “pins-and-needles” sensations of the groin and inner thighs which would contact a saddle when riding a horse.
- Bladder and bowel dysfunction, caused by a decreased tone of the urinary and anal sphincters.
- Detrusor weaknesses causing urinary retention and post-void residual incontinence as assessed by bladder scanning the patient after the patient has urinated.
- Sciatica type pain on one side or both sides, although pain may be wholly absent
- The weakness of the muscles of the lower legs (often paraplegia)
- Pain in one leg (unilateral) or both legs (bilateral) that starts in the buttocks and travels down the back of the thighs and legs (sciatica)
- Numbness in the groin or area of contact if sitting on a saddle (perineal or saddle paresthesia)
- Bowel and bladder disturbances
- Lower extremity muscle weakness and loss of sensations
- Inability to urinate (urinary retention)
- Difficulty initiating urination (urinary hesitancy)
- The decreased sensation when urinating (decreased urethral sensation)
- Inability to stop or control urination (incontinence)
- Reduced or absent lower extremity reflexes
- Local pain is generally a deep, aching pain resulting from soft tissue and vertebral body irritation.
- Leg pain (radicular pain) is generally a sharp, stabbing pain resulting from compression of the nerve roots.
- Radicular pain projects along the specific areas controlled by the compressed nerve (known as a dermatomal distribution).
- Inability to stop or feel a bowel movement (incontinence)
- Loss of anal tone and sensation
- Achilles (ankle) reflex absent on both sides.
- Sexual dysfunction
- Absent anal reflex and bulbocavernosus reflex
- Gait disturbance
Diagnosis of PLId
Straight leg raise
- a tension sign for L5 and S1 nerve root
- can be done sitting or supine
- reproduces pain and paresthesia in the leg at 30-70 degrees hip flexion
- sensitivity/specificity most important and predictive physical finding for identifying who is a good candidate for surgery
- crossed straight leg raise is less sensitive but more specific
- SLR aggravated by forced ankle dorsiflexion
- SLR aggravated by compression on popliteal fossa
- pain reproduced with neck flexion, hip flexion, and leg extension
- pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veinsMilgram test
- pain reproduced with straight leg elevation for 30 seconds in the supine position
- gait analysis
- Trendelenburg gait due to gluteus medius weakness which is innervated by L5.
Physical Examination of PLID
Observation of posture and function
- In standing, her shoulders were shunted to the left side, her back was extended and pelvis anteriorly tilted, and there was visible hyper-tonicity of the lumbar paraspinal muscles.
This shunted antalgic posture is commonly referred to as a lumber list. Observation of a lumbar list, unfortunately, is a test lacking in reliability (Clare, Adams, & Maher, 2003). Maitland (2005), however, teaches us that if a person presents with an observable postural deformity, they are going to be more challenging to get better. In Sally’s case, she had a contralateral list (shoulders listed to the opposite side of back/leg pain), which is thought to respond more favorably to treatment than an ipsilateral list.
In my experience antalgic postures are very important to detect because they indicate a protective position; a mechanism which the body is adopting (often subconsciously) in the acute phase of injury to protect the injury, and if the antalgic posture is not carefully examined and carefully corrected, it can make the patient a lot worse.
Active range of movement
- Lumbar flexion P2 (right-sided low back pain) R`(upper thigh).
- Extension P2 (right buttock and leg pain) R` (vertical).
- Other movements were not assessed day 1 due to severity and irritability.
- Weak single leg calf raise (SLCR) and was only able to perform three assisted raises to 50% range. Gr 5 strength of right leg SLCR x5 repetitions.
- No other myotomal weakness was detected.
- The S1 reflex on the right side was absent, with other lower limb reflexes being preserved.
- No sensory changes were noted.
- The straight leg raise test (SLR) was positive in reproducing Sally’s posterior thigh pain and limited at 20 degrees on the right side.
- Her left SLR was limited by hamstring tightness at 50 degrees.
The research suggests the SLR reliable re-assessment asterisks for patient progress. It has been shown to be 91% sensitivity and 26% specificity in detecting lumbar disc pathology.D Neville et al. (2012) found that more than an 11-degree discrepancy in hip flexion range between sides was a clinically significant result. Compared to MRI, the SLR test has poor diagnostic accuracy and therefore is often used in conjunction with such imaging.
Location of Pain and Motor Deficits in Association with Nerve Root Involvement at Each Lumbar Disc Level
|DISC LEVEL||LOCATION OF PAIN||MOTOR DEFICIT|
Pain in inguinal region and medial thigh
Pain in the anterior and medial aspect of upper thigh
Slight weakness in quadriceps; slightly diminished suprapatellar reflex
Pain in anterolateral thigh
Weakened quadriceps; diminished patellar or suprapatellar reflex
Pain in the posterolateral thigh and anterior tibial area
Weakened quadriceps; diminished patellar reflex
Pain in the dorsum of the foot
Extensor weakness of big toe and foot
Pain in the lateral aspect of the foot
Diminished or absent Achilles reflex
- Palpation was conducted in the left side lying position with pressure applied only to the onset of pain (P1).
- The presence of generalized hyperalgesia made it difficult to establish a comparable finding day.
Straight Leg Raise Test (SLR Test)
|Straight leg raise|
Straight Leg test sometimes used to help diagnose a lumbar herniated disc
SLR test and its Modifications
|SLR (BASIC)||SLR2||SLR3||SLR4||CROSS LEG
|HIP||Flexion and adduction||Flexion||Flexion||Flexion and medial Rotation||Flexion|
|NERVE BIAS||Sciatic Nerve and Tibial Nerve||Tibial Nerve||Sural Nerve||Common Peroneal Nerve||Nerve Root (Disc Prolapse)|
PLID Causes Symptoms Diagnosis
- A Cross-sectional study by Boyd and Villa (2012) examined normal asymmetries between limbs in healthy, asymptomatic individuals during SLR testing and the relationship of various demographic characteristics. The authors concluded that Overall range of motion during SLR was related to sex, weight, BMI and activity level, which is likely reflected in the high variability documented.
- We can be 95% confident that inter-limb differences during SLR neurodynamic testing fall below 11 degrees in 90% of the general population of healthy individuals. In addition, inter-limb differences were not affected by demographic factors and thus may be a more valuable comparison for test interpretation.
- Rabin et al. have shown the sensitivity of the SLR test to be.
- Deville et al. found the specificity to be.
- A systematic review of the Clinical utility of SLR by Scaia V, Baxter D and Cook C (2012) investigated the diagnostic accuracy of a finding of pain during the straight leg raise test for lumbar disc herniation, lumbar radiculopathy, and/or sciatica.
- The authors concluded that Variability in reference standard may partly explain the inconsistencies in the diagnostic accuracy findings.
- Further, pain that is not specific to lumbar radiculopathies, such as that associated with hamstring tightness, may also lead to false positives for the SLR; and may inflate the sensitivity of the test.
Diagnostic Test Accuracy Review (Cochrane Meta-analysis)-
Assessed the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica. The review included 16 cohort studies (median N = 126, range 71 to 2504) and three case-control studies (38 to100 cases). Only one study was carried out in a primary care population. Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35). Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations. The authors of the meta-analysis conclude that When used in isolation, current evidence indicates the poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.
Symptoms of lumbar disk disease
The symptoms of lumbar disk disease vary depending on where the disk has herniated, and what nerve root it is pushing on. The following are the most common symptoms of lumbar disk disease. However, each individual may experience different symptoms. Symptoms may include:
- Intermittent or continuous back pain. This may be made worse by movement, coughing, sneezing, or standing for long periods of time.
- Spasm of the back muscles
- Sciatica. Pain that starts near the back or buttock and travels down the leg to the calf or into the foot.
- Muscle weakness in the legs
- Numbness in the leg or foot
- Decreased reflexes at the knee or ankle
- Changes in bladder or bowel function
The symptoms of lumbar disk disease may resemble other conditions or medical problems. Always consult your health care provider for a diagnosis.
Lab Diagnosis of PLID
A doctor can diagnose cauda low back pain. Here’s what you may need to confirm a diagnosis
- A medical history – in which you answer questions about your health, symptoms, and activity.
- A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
- Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
- Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
- Elevated CRP – levels are associated with infection.
- Magnetic resonance imaging (MRI) scan – which uses magnetic fields and computers to produce three-dimensional images of your spine.
- A myelogram – an X-ray of the spinal canal after injection of contrast material — which can pinpoint pressure on the spinal cord or nerves.
- A computed tomography (CT) scan.
- Urodynamic studies – may be required to monitor recovery of bladder function following decompression surgery.
- In most cases of low back pain, medical consensus advises not seeking an exact diagnosis but instead beginning to treat the pain. This assumes that there is no reason to expect that the person has an underlying problem. In most cases, the pain goes away naturally after a few weeks. Typically, people who do seek diagnosis through imaging are not likely to have a better outcome than those who wait for the condition to resolve.
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