Tag Archive Treatment of PLID

PLID (Prolapse lumbar intervertebral disc) is one of the most common, chronic lumbar vertebral column diseases of elderly people leading to back pain, low back pain, sciatica, quadra equines syndromes, radicular pain, and subsequently neurological deficit due to nerve root compression that leads to radiating pain up to whole lower limb. [rx,rx,rx] The lumbar intervertebral disc is a complex structure composed of collagen, proteoglycans, glycosaminoglycan, 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 the catastrophic failure of the annular fibers.[Rx]

PLID (Prolapse lumbar intervertebral disc), also known as a slipped disc, is a medical condiververtibral dissection 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, and PLID.
• 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.
• The lumbar disc is a fibrocartilaginous structure that is seated between two vertebral body endplates. It is composed of an internal gelatinous nucleus pulposus and an external fibrous annulus fibrosus. The primary function of the lumbar disc is shock absorption. Two longitudinal ligaments lie anterior and posterior to the vertebral body. The anterior longitudinal ligament resists lumbar extension, translation, and rotation. The posterior longitudinal ligament resists lumbar flexion. The segmental ligaments include the ligamentum flavum, which is perforated when performing a lumbar puncture. The remaining segmental ligaments include the supraspinous and interspinous ligaments which lie between the spinous processes and resist lumbar flexion.[rx][rx]

(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.

Physiology of Anatomy of Spine 

Complete intervertebral disc anatomy and biomechanics and disc composition. Each disc is made up of 3 main components. These components include the nucleus pulposus (NP), the annulus fibrosis (AF) and the cartilaginous endplates (CEP)[rx] The cartilaginous endplates are composed of a small amount of hyaline cartilage that is located between the vertebral endplate and the NP.[rx] It is made up of water, type II collagen, chondrocyte-like cells, and proteoglycans (sulfated glycosaminoglycans). These constituents help the NP to be elastic, allow it to be flexible under stress, and resist compression.[rx] The high amount of sulfated glycosaminoglycans gives the nucleus pulposus a high charge density which causes the NP to absorb water and swell, which gives it the ability to act like both a solid and a liquid in mechanical situations.[rx]

The annulus fibrosis

The annulus fibrosus is the type I collagen surrounding the nucleus pulposus in approximately 15-20 layers. Together, the annulus fibrosis and nucleus pulposus form the intervertebral disc between adjacent vertebrae. The annulus fibrosus runs obliquely between edges of adjacent vertebrae, connecting the inferior endplate of the superior vertebra with the superior endplate of the inferior vertebra. The directions of the layers of the annulus fibrosus alternate which adds to the strength of the annulus fibrosus. Near the central region, the annulus fibrosus blends with the nucleus pulposus. The posterolateral aspect of the annulus fibrosus has a greater content of vertically oriented fibers leading to relative focal weakness at the posterolateral aspect.

• Composed of type I collagen, water, and proteoglycans
• Characterized by extensibility and tensile strength
• High collagen / low proteoglycan ratio (low % dry weight of proteoglycans)
• Asymptomatic Annular Tear  – If the annular tear or fissure is identified incidentally, then no treatment is warranted. Such annular fissures may resolve spontaneously over time and are frequently due to the stresses applied to the spine and causes PLID. It is posited that some asymptomatic annular tears may become symptomatic with time, but there is currently no definitive evidence that the treatment of asymptomatic annular tears provides any benefit or prevents any future issues.[rx]
• Symptomatic Annular Tear without Disc Protrusion or Herniation  – An annular fissure or tear can be symptomatic without disc protrusion or herniation. It is suspected that local inflammatory reactions from the annulus fibrosus tear or fissure lead to irritation of adjacent nerve fibers or traversing nerve roots.[rx]

Nucleus pulposus

The nucleus pulposus is composed of water, type II collagen, chondrocyte-like cells, and proteoglycans. This unique composite allows the NP to be elastic, flexible under stress forces and to absorb compression.[rx] The composition of the AF is mainly concentric layers of collagen type I fibers,[rx] forming a fibrous tissue with helical disposition surrounding the NP, this structure is denser in the anterior part and is attached to the vertebral body by Sharpey fibers.

• 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

Lumbosacral Nerve Root and innervation Anatomy

• L1 nerve root – Exits between L1 and L2 foramina, innervates iliopsoas muscle, sensory distribution, upper third thigh, assessed with the cremasteric reflex (male).
• L2 nerve root – Exits between L2 and L3 foramina, innervates iliopsoas muscle, hip adductor, and quadriceps, sensory distribution, middle third thigh, no reflex.
• L3 nerve root – Exits between L3 and L4 foramina, innervates iliopsoas muscle, hip adductor, and quadriceps, sensory distribution, lower third thigh, no reflex.
• L4 nerve root – Exits between L4 and L5 foramina, innervates quadriceps and tibialis anterior, sensory distribution, anterior knee, medial side of the leg, assessed with patellar reflex.
• L5 nerve root – Exits between L5 and S1 foramina, innervates extensor hallucis longus, extensor digitorum longus, and brevis, and gluteus medius, sensory distribution: anterior leg, lateral leg, and dorsum of the foot, no reflex.
• S1 nerve root – Exits between S1 and S2 foramina, innervates gastrocnemius, soleus, and gluteus maximus, sensitive distribution, posterior thigh, plantar region, assessed with Achilles reflex.

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 the transition

Horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root

• Because of the vertical anatomy of the lumbar nerve root, a paracentral and foraminal disc will affect different nerve roots
• Because of the horizontal anatomy of the cervical nerve root, a central and foraminal disc will affect the same nerve root

Location 

Central Prolapse

• Often associated with back pain only
• May present with cauda equina syndrome which is a surgical emergency

Posterolateral (paracentral)

• Most common (90-95%)
• PLL is weakest here
• Affects the traversing/descending/lower nerve root
• At L4/5 affects the L5 nerve root

Foraminal (far lateral, extraforaminal)

• Less common (5-10%)
• Affects exiting/upper nerve root
• At L4/5 affects the L4 nerve root
• L5 at the L5/S1 level, a disc herniation far laterally into the left/right neural foramen would compress the L5 nerve, resulting in weakness of hip abduction muscles, ankle dorsiflexion (anterior tibialis muscle) and/or extension of the great toe (extensor hallucis longus muscle).
• S1 at the L5/S1 level, a disc herniation centrally into the canal would compress the S1 nerve, resulting in weakness of ankle plantar flexion (gastrocnemius muscle).

Axillary

• Can affect both exiting and descending nerve roots
• A disc herniation at the L5/S1 level can have two overlapping presentations

Anatomic

• Protrusion > eccentric bulging with an intact annulus
• Extrusion > disc material herniates through the 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
• Disc herniation material  (i.e., herniated nucleus pulposus, HNP)
  • Varying degrees of HNP are recognized, from disc protrusion (annulus remains intact), extrusion (annular compromise, but herniated material remains continuous with disc space), to sequestered (free) fragments.
  • HNP material predictably is resorbed over time, with the sequestered fragment demonstrating the highest degree of resorption potential
  • In general, 90% of patients will have an asymptomatic improvement in radicular symptoms within 3 months following nonoperative protocols alone.

• Hypertrophy/expansion of degenerative tissues

  • Common sources include ligamentum flavum and the facet joint.  The facet joint itself undergoes degenerative changes (just like any other joint in the body), and synovial hypertrophy and/or associated cysts can compromise surrounding nerve roots.

Types of PLID

According to the position of the spinal disc herniation are 4 types

Herniation may develop suddenly or gradually over weeks or months. The 4 stages of a PLID are

• 1) Disc Degeneration or Bulsing Disc – Chemical changes associated with aging causes discs to weaken, but without a herniation.
• 2) 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.
• 3) Extrusion – The gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
• 4) 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 the 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 exits.
• 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) – Osteophytes are bony lumps (bone spurs) that grow on the bones of the spine or around the joints. They often form next to joints affected by osteoarthritis, a condition that causes joints to become painful and stiff.

• Bone spurs – 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

Degenerative

• lumbar disc herniation (most common, especially at L4/5 and L5/S1)
• lumbar spinal canal stenosis
• spondylolisthesis
• Tarlov cysts
• Facet joint cysts

Trauma

• 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 a partial dislocation (subluxation) of the low back (lumbar spine) that can cause sciatica syndrome.

Herniated Disk

• 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 involve large particles of disk material that have completely separated from the normal disk and compress the nerves (extruded disk herniation). In most cases, the disk material takes up at least one-third of the canal diameter.

Spinal Stenosis

• 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

Tumors (Neoplasms)

• 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.

Inflammatory Conditions

• 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.

Infectious Conditions

• 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 a 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 oftentimes 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

Diagnosis of PLId

History

Your doctor may ask about medical history in which you answer questions about your health, symptoms, and activity. Previous disease condition, fracture, lifestyle, geographical location, food habit, and acute and chronic disease, drug addictions, occupation of the patient. In the lumbar spine, a herniated disc can present with symptoms including sensory and motor abnormalities limited to a specific myotome. History in these patients should include chief complaints, the onset of symptoms, where the pain starts and radiates. History should include if there is any past treatment history.

Pain history for PLID is-

• Duration – How long the pain is present?
• Onset – How did it start?
• Progress – What happened afterward?
• Site – Where do you feel the pain, point it out with a single finger?
• Character – What is the nature of pain? Is it throbbing, pricking, or burning type of pain?
• The intensity of pain – What is the severity of pain at present, at rest, and during activity? How severe was the worst pain you experienced?
• Temporal factors – Continuous or intermittent, diurnal variation.
  • Is the pain continuous or intermittent?
  • If intermittent, how long does each episode last?
  • If intermittent, is it colicky in nature?
  • Is there any relation between the severity of pain and the time of day?
  • Is there any sleep disturbance due to pain?
• Aggravating factors.
  • Is it aggravated by activity? Suggestive of mechanical pain.
  • Is it aggravated when getting up in the morning? If yes, how long does the increased pain last? Morning stiffness is present if the pain lasts for more than one hour. Morning stiffness is suggestive of inflammatory spondyloarthropathy.
  • Is it aggravated by walking? Suggestive of vascular or neurogenic claudication.
  • Is it aggravated by standing? Suggestive of neurogenic claudication.
• Relieving factors.
  • Is it relieved by activity? Suggestive of inflammatory spondyloarthropathy.
  • Is it relieved by rest? Suggestive of mechanical pain.
  • If aggravated by walking, is it relieved by standing? Suggestive of vascular claudication.
  • If aggravated by standing and walking, is it relieved by sitting down or stooping forwards? Suggestive of neurogenic claudication.
• Manual palpation Test
  • Palpation was conducted on 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.

Physical exam

A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion.

A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location, and reflex loss associated with the different levels are described in Table 2.

• L1 Nerve – pain and sensory loss are common in the inguinal region. Hip flexion weakness is rare, and no stretch reflex is affected.
• L2-L3-L4 Nerves  – back pain radiating into the anterior thigh and medial lower leg; sensory loss to the anterior thigh and sometimes medial lower leg; hip flexion and adduction weakness, knee extension weakness; decreased patellar reflex.
• L5 Nerve – back, radiating into buttock, lateral thigh, lateral calf and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex.
• S1 Nerve – back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.
• S2-S4 Nerves – sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.
• 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 plantarflexion (S1)
• Have the patient do 10 single leg toes stand

Manual Test For PLID

Straight Leg Raise ( SLR) 

The Straight Leg Raise (SLR) test is a neurodynamic test. SLR is a neural tension test that can be used to rule in or out neural tissue involvement as a result of a space-occupying lesion, often a lumbar disc herniation. It is one of the most common neurological tests of the lower limb.

• 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.

Contralateral SLR

• Crossed straight leg raise is less sensitive but more specific. Radicular pain in the affected leg when the contralateral asymptomatic leg is similarly raised constitutes a positive crossed straight-leg raise (X-SLR) test.

League sign

• SLR aggravated by forced ankle dorsiflexion. Lasegue sign or straight leg raising test (SLRT) is a neurodynamic exam to assess nerve root irritation in the lumbosacral area.[rx] It is an integral element to the neurological exam for patients presenting with low back pain with or without radicular pain. The other less commonly used name is the Lazarevic sign.

Kernig test

• Pain reproduced with neck flexion, hip flexion, and leg extension. Kernig’s sign is a test used in physical examination to look for evidence of irritation of the meninges. The test involves flexing the thighs at the hip, and the knees, at 90-degree angles, and assessing whether the subsequent extension of the knee is painful (leading to resistance), in which case it is deemed positive.

Naffziger test

A maneuver used to identify compression of nerve roots in the cervical spine, based on exacerbation of pain and paraesthesias of the hand and fingers, when the examiner exerts pressure on the scalenus anterior muscles in patients with scalenus anterior syndrome. (for nerve root compression) increase or aggravation of pain or sensory disturbance over the distribution of the involved nerve root upon manual compression of the jugular veins bilaterally confirms the presence of an extruded intervertebral disk or other mass.

• Pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins Milgram 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.

Quadrant Test

• Position of patient – Standing
• Position of examiner – Standing behind the patient
• Procedure – Keep one hand over the patient’s contralateral shoulder and apply axial pressure. Ask the patient to hyperextend, rotate and laterally flex to the contralateral side.
• Interpretation – Provocative pain is taken as a sign of lumbar instability.
• Use – Used if pain cannot be produced by forwarding flexion, lateral flexion etc.

Adams Forward Bending Test

• Position of patient – Standing with feet together, knee extended.
• Position of examiner – Standing behind the patient first then in front of the patient.
• Procedure – Rule out limb length discrepancy. Ask the patient to bend forwards at the waist till the back is in the horizontal plane. Palms should be held together.
• Interpretation – If there is a rib or loin hump present, then there is structural scoliosis with rotation.
• Use – To differentiate between structural and non-structural scoliosis.
• Validity of test –  For a patient with 40 structural scolioses, the test has a sensitivity of 0.83 and a specificity of 0.99.

Additional manual test for nerve root compression

• Crossed SLRT – AKA well-leg raising test or Fajersztajn sign. When the contralateral leg is lifted, the patient experiences pain on the affected side. [rx][rx]This test is more specific than ipsilateral SLRT. It becomes positive, usually in severe compression and centrally located prolapse. Fajersztajn believed that this sign is due to disc prolapse in the axilla of the root.[rx]
• Reverse SLRT – AKA femoral stretch or Ely test. While the patient is in a prone position, the leg is lifted off the table with both hip and knee joints extended. Some authors may allow knee flexion. This maneuver may reproduce radicular pain in the case of upper lumbar radiculopathy, far lateral lumbar disc, or femoral neuropathy. The pain will present in the femoral nerve distribution on the side of the lesion.[rx]
• Braggart test – AKA Sciatic stretch test or Flip test. While raising the leg, the foot is held in a dorsiflexed position so that the sciatic nerve is stretched more, thereby increasing the intensity of pain or making it possible to elicit the sign early.[rx][rx]
• Reverse flip test – While raising the leg, the foot is held in a plantar-flexed position; this will lessen the pain. But if the patient is complaining of an increase in pain, it can suggest malingering.[rx]
• Bowstring sign – Also known as the popliteal compression test or posterior tibial nerve stretch sign. The patient can be examined in sitting or in a supine position. The examiner flexes the knee and applies pressure on the popliteal fossa, evoking sciatica. Some examiners do it after SLRT by flexing the knee to relieve the buttock pain. The pain would be reproduced by a quick snap on the posterior tibial nerve in the popliteal fossa.[rx]

Less frequently used nerve root irritation tests For PLID

For the sake of completion, other tests and signs of nerve root tension or irritation are discussed succinctly below

• Sitting SLRT (Bechterew test) – the patient is made to sit at the edge of a table with both hip and knee flexed, then made to extend the knee joint or elevate the extended knee, which reproduces the radicular pain. They may be able to extend each leg alone, but extending both together causes radicular pain.[rx]
• Distracted SLRT – the sitting SLRT is performed without the patient’s awareness. The patient is distracted as if the surgeon is examining the foot or pulsation, and slowly, the examiner extends the knee. If the patient is experiencing true radiculopathy, the same pain will be reproduced. Otherwise, we can assume that the patient may be malingering.
• Neri’s sign – while bending forward, the patient flexes the knee to avoid stretching the nerve.[rx]
• The buckling sign[rx] – the patient may flex the knee during SLRT to avoid sciatic nerve tension.
• Sicard sign – passive dorsiflexion of ipsilateral great toe just at the angle of SLRT will produce more pain.
• Kraus-Weber test – the patient may be able to do a sit-up with the knees flexed but not extended.
• Minor sign – the patient may rise from a seated position by supporting himself/herself on the unaffected side, bending forward, and placing one hand on the affected side of the back.
• Bonnet phenomenon – the pain may be more severe or elicited sooner if the test is carried out with the thigh and leg in a position of adduction and internal rotation.[rx]

Provocative Tests In A Spinal Examination and PLID

• Shoulder Abduction (Relief) sign – Active abduction of symptomatic arm achieved by patient placing their ipsilateral hand on their head. A positive test results in relief (or reduction) of cervical radicular symptoms.
• Neck Distraction test – Active distractive force is applied by the examiner while grasping the patient’s head under the occiput and chin. A positive test results in relief (or reduction) of cervical radicular symptoms.
• L’hermitte’s sign – Examiner passively flexes patient’s cervical spine. A positive test result is an electric shock-like sensation down the spine or extremities.
• Hoffman’s sign – Passive snapping flexion of distal phalanx of patient’s middle finger. A positive test results in flexion-adduction of the ipsilateral thumb and index finger.
• Adson’s test – Patient is instructed to inspire with chin elevated, and head rotated to the affected side. A positive test results in obliteration of radial pulse.
• The Spurling test – is designed to reproduce symptoms by compression of the affected nerve root. The cervical extension is used to induce/reproduce posterior bulging of the intervertebral disk. Rotation of the head causes narrowing of the neuroforamina in the cervical spine. Finally, axial compression is applied to amplify these effects with the aim of exaggerating the preexisting nerve root compression.
• The prone instability test – The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso onto the couch.  The patient can hold onto the couch’s sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine, while the feet are off the floor, is considered positive. [rx]
• Prone Plank/Bridge – The patient is prone and elevates his / her entire body off the couch/mat on forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.[rx]
• Supine Bridge – The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- 30s. [rx]

Clinical Tests For Instability for PLID

• Aberrant movement on flexion-extension – The standard examination involves documenting the range of movement. The quantitative range of movement may not be as significant as the qualitative range of movement. The important feature of spinal instability is the aberrant motion that occurs when flexing and extending the spine. A catch, a painful arc, supporting the arms on the thighs, or a reversal of the lumbopelvic rhythm when standing from the flexed posture indicates instability.[rx]
• Passive lumbar extension test – The subject lies on the examination couch. The examiner passively lifts the lower limbs to a height of 30 cm from the coach while maintaining the knee in extension and applying gentle traction on the legs. A positive test is recorded if the patient complains of “pain in the lower back region” or complains of “heaviness in the lower back” or complains that, “the lower back is coming off.” These experiences should return to normal when the leg returned to the couch. The passive lumbar extension test has the highest combined sensitivity and specificity and may be comparable to radiological findings to identify lumbosacral structural instability.[rx]
• The prone instability test – The patient stands at the foot end of the examination couch. The patient then lowers his/her upper body to rest on the examination couch. The iliac crest should rest on the edge of the examination couch. The patient holds the sides of the examination couch for increased stability. In the first part of the test, the feet of the patient is resting on the ground. The examiner with the heel of his/her hand creates a small posterior to anterior trust at each segment of the lumbar spine. Pain, if experienced by the patient, is recorded. In the second part of the test, the patient is asked to lift the feet of the floor and steady himself /herself by holding onto the sides of the examination couch. The examiner again repeats the posterior to anterior trust with the heel of his/her hand at each lumbar segment. The test is positive if the pain created in the initial part of the test subsides when the extensor muscles of the spine are tensed by lifting the feet of the floor.[rx]

Clinical Tests For Endurance in PLID

• Sorensen test – The legs of the patient are strapped onto a low platform, which is only 25 cms above the floor.  The upper end of the iliac crest is aligned to the edge of the table. The upper torso rests on the floor. At the commencement of the test, the patient extends the spine and lifts the upper torso off the floor with the arms crossed across the chest, and is asked to maintain the horizontal position. The record of the time, the patient can maintain this position is documented.  Normative values: Men 146 +/- 51. Women 189 +/- 60.[rx]
• Prone isometric chest raise – The patient lies prone on the examination couch with a pad underneath the abdomen and the arms along the sides. The patient is instructed to lift the upper trunk about 30 degrees from the table while keeping the neck flexed, and the intention is to hold the sternum of the surface of the couch. The clinician records the maximum time that the patient can hold this position. [rx]Normative values: Men 40 +/- 9. Women 52 +/- 18.[rx]
• Prone double straight leg raise – The patient lies prone on the examination couch with the hips extended and the hands underneath the forehead. The arms are perpendicular to the body. The patient is then requested to lift both the legs off the couch until the knee is cleared off the couch. The patient should maintain normal breathing during the entire test procedure. The examiner can monitor the knee clearance by sliding a hand under the knee. The clinician records the maximum time that the patient can hold this position. Normative values: Men 38 +/- 6. Women 35 +/- 5. The prone double straight leg raise has shown to have great sensitivity and specificity. [rx]
• Supine static chest raise – The patient lies supine on the couch with the legs extended. The hands are placed on the temples with the elbows pointing to the ceiling.  The patient is then instructed to lift the head, the arms and the upper trunk of the couch. The patient should maintain normal breathing during the entire test procedure. The clinician records the maximum time that the patient can hold this position. Normative values: Men 43 +/- 9. Women 32 +/- 5. [rx]
• Supine double straight leg raise – The patient lies supine with the legs extended, and the arms crossed in front of the chest. The pelvis is tilted forward to increase the lumbar lordosis. The patient is then requested to lift both the legs of the floor for 30 degrees while maintaining normal breathing during the entire test procedure. To monitor the pelvic tilt, the examiner can place one hand under the lumbar spine.  The clinician records the maximum time that the patient can hold this position. Normative values: Men 28 +/- 4. Women 28 +/- 4. [rx]
• Flexor endurance test – The patient is supine on the couch with the upper part of the body propped up on a support. The support is at an angle of 60 degrees. The legs are flexed so that the knee is at a 90-degree angle with the foot flat on the couch. The toes and feet are strapped to the couch to provide a counterbalance. In a modified procedure, the examiner sits on the edge of the couch and over the toes of the patient to provide a counterbalance. The arms are crossed across the chest towards the opposite shoulder. The support is moved back by 10 cms, and the patient is instructed to maintain the original position. The clinician records the maximum time that the patient can hold this position. Normal values: Men 144 +/- 76, Women 149 +/- 99 in normal subjects.[rx]
• Prone Plank/Bridge – The patient lies prone on a mat. Initially, the patient lifts his / her upper torso off the mat and steadies on the elbows and forearms. The elbow is directly below the shoulder, and the forearms are straight with hands in front of the elbow. The patient then lifts the pelvis off the mat. The body is now supported on the elbow/forearm and the tips of the toes. The patient maintains a rigid horizontal position parallel to the floor. The clinician records the maximum time that the patient can hold this position. Normative values: Men 124 +/- 72s, Women 83 +/- 63s.[rx]
• Supine Bridge – The patient lies supine with the legs flexed so that the knee is at a 90-degree angle, and the foot is flat on the couch but not touching each other. The elbows are bent, and the hands are placed on the ears. The patient then lifts the pelvis so that the shoulders, hips, and knees are in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 188 +/- 45s, Women 152 +/- 30s.[rx]
• Side Plank/Bridge – The patient lies on the side on a mat. The upper part of the body is lifted off the mat and supported on the elbow of the arm below. The opposite (upper) arm crosses across the chest onto the lower shoulder. The top foot is positioned in front of the lower foot. The patient is then instructed to lift the pelvis off the floor and to maintain the trunk and the legs in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 95 +/- 35s, Women 74 +/- 33s.[rx]

Waddell Signs for PLID Include

• Superficial tenderness – The patient’s skin over a wide area of the lumbar skin is tender to light touch or pinch.
• Non-anatomical tenderness – The patient experiences deep tenderness over a wide area that is not localized to one structure and crosses over non-anatomical boundaries.
• Axial loading – Downward pressure on the top of the patient’s head elicits lumbar pain.
• Acetabular rotation – Lumbar pain is elicited while the provider passively and simultaneously externally rotates the patient’s shoulder and pelvis together in the same plane as the patient stands. It is considered a positive test if pain occurs within the first 30 degrees of rotation.
• Distracted straight leg raises discrepancy – The patient complains of pain during a straight leg raise during formal testing, such as when supine, but does not on distraction when the examiner extends the knee with the patient in a seated position.
• Regional sensory disturbance –The patient experiences decreased sensation fitting a stocking-like distribution rather than a dermatomal pattern.
• Regional weakness – Weakness, cogwheeling, or the giving way of many muscle groups that are not explained on a neuroanatomical basis.
• Overreaction – A disproportionate and exaggerated painful response to a stimulus that is not reproduced when the same provocation is given later. These responses can include verbalization, facial expression, muscle tension, or tremor.[trx],[rx]

Evidence

• 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 the 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.

Lab Test For Diagnosis of PLID

A doctor can diagnose cauda’s low back pain or PLID. Here’s what you may need to confirm a diagnosis

• 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.
• RBS – To diagnosis, diabetes and it related health problem, burning sensation etc
• Rheumatoid factor and anti-CCP – cyclic citrullinated peptide antibodies test should be increased if there is clinical abnormality for PLID or right and left side back pain are found.
• A serum uric acid level – It is often considered by clinicians and doctors when PLID is suspected, but it is not a reliable and dangerous condition of your kidney as it may be spuriously elevated or high in acute inflammatory conditions or acutely during an attack or not.
• Serologic studies – There are no blood tests used to specifically support the diagnosis of nerve compression, demyelination but the use of these tests may be necessary for medical conditions that can either increase nerve compression or can decrease their symptoms. Some of the most frequently find conditions include diabetes and hypothyroidism. The assessment of a patient’s fasting blood glucose, hemoglobin A1c, or thyroid function tests may be helpful in the general management of the patient. Other conditions that could mimic nerve compression include deficiency of vitamin B12 or folate, vasculitides, and fibromyalgia.
• Synovial fluid analysis – A joint arthrocentesis or the system of aspiration of synovial fluid with blood and synovial fluid analysis that are mandatory if an infection is suspected or dangerous. Such as the patients should also be started properly treatment by using empiric antibiotic therapy as soon as possible if the synovial fluid sample is obtained from the lumber joint. The fluid analysis or any kinds of abnormalities is also helpful in diagnosing crystal formation with osteophyte and steroid-induced arthritis. The degree of the high elevation of synovial fluid are founded by WBC count can be useful in differentiating inflammatory abnormality or from non-inflammatory causes of right and left side neck pain.

Imaging Test For PLID

• X-rays – can show the alignment of the bones and whether the patient has arthritis or broken bones. They are not ideal for detecting problems with muscles, the spinal cord, nerves, or disks.
• Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc is damage and is good for revealing herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
• Bone scan – a bone scan may be used for detecting bone tumors or compression fractures caused by brittle bones (osteoporosis). The patient receives an injection of a tracer (a radioactive substance) into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
• Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with a bulging disc. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression. It can also detect bony overgrowth, spinal cord tumors, or abscesses.
• Nuclear Magnetic resonance imaging (MRI) scan – which uses magnetic fields and computers to produce three-dimensional images of your spine.
• A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, PLID, a bulging disc in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, spinal cord tumors, and abscesses.
• Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc and PLID. [rx][rx]
• Discogram – A discogram may be recommended to confirm which bulging disc and PLID is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure. It is useful for the evaluation of patients who are experiencing cervical discogenic pain or have multiple herniations in which surgery is a strong possibility. However, the diagnostic procedure remains controversial as it may accelerate the degeneration of normal discs.[rx]
• CT myelogram – CT is most useful when combined with the injection of intrathecal contrast (myelography) to better evaluate the location and amount of neural compression. It is more invasive than an MRI but can be a consideration in patients who have a contraindication to MRI (e.g., pacemaker) or have an artifact from the hardware.
• Cerebrospinal fluid analysis – is a useful test if there is a suspected neoplasm or infectious cause or radiculopathy symptoms. The recommendation for a lumbar puncture is in the case of a patient with negative or nondiagnostic neuroimaging, without known primary cancer, who has progressive neurological symptoms and has failed to improve promptly.[rx]
• Bone scintigraphy – with single-photon emission computed tomography (SPECT) is more sensitive in detecting facet joint lesions and allows more accurate anatomical localization. A recent study suggested that SPECT could help to identify patients with low back pain, PLID who would benefit from facet joint injections [rx].
• Foraminal nerve root entrapment test – is best visualized on T1-weighted MRI where the high contrast between fat tissue and the nerve root sheath is of great help. Usually, a combination of hypertrophic degenerative facets with osteophytes spurs posteriorly, and vertebral osteophytes and PLID/or disc herniation anteriorly diminish the anteroposterior diameter of the foramen. Foraminal height is lessened by degenerative disc disease and subsequent disc height loss. Whenever the normal rounded (oval) appearance of the nerve root sheath is lost in combination with loss of the surrounding fat tissue, nerve root compression should be considered.
• Urodynamic studies – may be required to monitor the recovery of bladder function following decompression surgery.
• Electrodiagnostic studies – Electromyography and nerve conduction test studies help to localize the nerve problem involved as well as where along the course of the nerve it is affected. Additionally, testing can serve as a baseline for comparison with the future during the course of treatment. It is important to note that normal electrodiagnostic studies do not identify disease, and clinical correlation should include the patient’s history and physical examination findings.[rx]

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.

Treatment of PLID

Non-surgical

• Rest – It is important that the patient take proper rest and sleep and avoid any activities which will further aggravate the disc bulge and its symptoms. Many minor disc bulges can heal on their own with rest and other conservative treatments.
• Cervical Pillow – It is important to use the right pillow to give your neck the right type of support for healing from a cervical and lumbar disc bulge and also to improve the quality of sleep. Specific treatment for lumbar disk disease will be determined by your health care provider based on
  • Your age, overall health, and medical history
  • The extent of the condition
  • Type of condition
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Typically, conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.

• Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.

• Hot Bath –  Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.
• Traction – traction is the best essential treatment for bulging discs, pinched nerves, radiating pain management. It can be done in a manual and dynamic way to relieves pain in bulging discs.

• Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower back pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
• Heating and cooling – This includes the use of hot packs and heating patches, a hot bath, going to the sauna or using an infrared lamp. Heat can also help relax tense muscles. Cold packs, like cold wraps or gel packs, are also used to help soothe irritated nerves.
• Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
• Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
• Back school –  is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
• Patient education – on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
• Hot tub therapy – is a tried-and-true method of relieving stress, relaxing muscles, and experiencing renewal through warm water immersion. It is an ancient practice. People have been enjoying warm water immersion for centuries. Ancient Egyptians, Greeks, and Romans, for example, built palaces around natural hot springs.
• Physical therapy – which may include ultrasound, massage, conditioning, and exercise. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury. Physical therapists can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness.
• Over the Door Traction – This is a very effective treatment for a disc bulge. It helps in relieving muscle spasms and pain. Typically a 5 to 10-pound weight is used and it is important that patients do this under medical guidance.
• Weight control – By keto diet or maintaining or changing the food habit to reduce the weight not any movement during the time of acute pain.
• Use of lumbosacral back support – It is helpful for back support during any travels or everyday natural movement. It also helps to straighten the lumbar spine.
• Holistic therapies – Some patients find acupuncture, acupressure, nutrition/diet changes, meditation, and biofeedback helpful in managing pain as well as improving overall health.
• Braces – For patients with chronic back pain, PLID, or a deformity in the spine, the doctor may recommend wearing a brace to provide support. Back braces can help to maintain proper posture, limit strenuous movement, and realign the spine to provide relief from pain.
• Reiki – Reiki is a Japanese treatment that aims to relieve pain by using specific hand placements.
• Moxibustion –  This method is used to heat specific points on the body by placing heated needles or glowing sticks made of mugwort (“Moxa”) close to those points.
• Pilates – A total body workout in which strengthening the deep core muscles is key.
• Tai chi – Originally an Asian martial art, tai chi is now practiced with slow, flowing movements. It can improve your balance and coordination skills, strengthen your muscles, and is said to help you relax your body and mind.
• Going on walks – Initial research suggests that going on a walk or brisk walking (Nordic walking) can help relieve back pain if done regularly – for instance, every two days for 30 to 60 minutes.
• Alexander Technique – The Alexander Technique is a taught self-care discipline that enables an individual to recognize, understand, and avoid habits adversely affecting muscle tone, coordination, and spinal functioning. Priority is given to habits that affect freedom of poise of the head and neck and that lead to stiffening and shortening of the spine, often causing or aggravating the pain.
• Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal back pain of all types. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
  • In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.

Medications

• Analgesics – It is basically paracetamol with prescription-strength drugs that relieve pain but not inflammation.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes paresthesia, radiating pain with numbness, diabetic neuropathy pain, myalgia, burning, numbness, and tingling sensation
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen.
• Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages may be taken.[rx]
• Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
• Dietary supplement  – A dietary supplement is a manufactured product intended to supplement one’s diet by taking a pill, capsule, tablet, powder, suspension, or liquid to remove general weakness & improved health.^[rx] A supplement can provide micronutrients either extracted from plants, seafood sources that are synthetic in order to increase the quantity of their consumption PLID. The class of nutrient compounds includes all kinds of vitamins, minerals, fiber, fatty acids, and amino acids.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Triamcinolone acetonide Injection with local anesthesia – In lumbar epidural analgesia, the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or C- arms electromyography to make sure that the injection is placed at exactly the right spot.[rx]
• Chemonucleolysis and chymopapain – Chemonucleolysis is a technique that is now rarely used. It attempts to decrease the volume of disc herniation by reducing the amount of material contained within the nucleus pulposus by injecting the enzyme chymopapain. Some scientific, systematic review of a lumbar discectomy with percutaneous treatments identified three RCTs that compared chymopapain with other placebo injections and reported that symptom relief was greater in the group that received chymopapain.^[rx]
• Collagenase Injection – Collagenase injections provide an invasive treatment derived from Clostridium histolyticum. The injection is a form of the enzyme is a metalloprotease that lyses in collagen (sparing Type IV collagen which is needed in the basement membrane of blood vessels and nerves). Treatment typically consists of 0.25 mL for contracture muscle into the spinal cord and 0.20 mL are injected in the PLID rehabilitation stage to prevent contractures delivered subcutaneously directly into the spinal cord with a needle. The affected area is manipulated under local anesthesia at 24 to 48 hours after injection. Collagenase injections have been shown to effectively result in a 75% in post-operative back muscle contracture reduction with a 35% recurrence rate. Complications of injections include edema, swelling skin tearing, tendon rupture, complex regional pain syndrome, and pulley rupture, etc.[rx]
• Steroid injections – The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves. About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.

Caution: individuals with diabetes and those who may be predisposed to diabetes should note that prolonged use of corticosteroids can make it difficult to regulate insulin levels.

Surgical Treatment 

There are a number of surgical procedures performed on the lumbar spine, especially for degenerative, infective, and traumatic spinal conditions. A few of them are:

• Pedicle screw fixation
• Laminectomy
• Posterior Lumbar Interbody Fusion [rx]
• Transforaminal Lumbar Interbody Fusion [rx]
• Extreme Lateral Interbody Fusion [rx]
• Anterior Lumbar Interbody Fusion [rx]
• Oblique Lumbar Interbody Fusion [rx]
• Corpectomy

When these conservative measures fail, surgery for the removal of a herniated disk may be recommended. Surgery is done under general anesthesia. An incision is placed in the lower back over the area where the disk is herniated. Some bone from the back of the spine may be removed to gain access to the area where the disk is located. Typically, the herniated part of the disk and any extra loose pieces of a disk is removed from the disk space.

• Microdiscectomy – for a herniated disc, a minimally invasive procedure in which the herniated portion of the disc is removed.
• Artificial disc replacement – for degenerative disc disease and herniated discs is a minimally invasive procedure that replaces a damaged disc with a specialized implant that mimics the normal function of the disc, maintaining mobility.
• Spinal fusion – fusion for degenerative disc disease, in which the disc space is fused together to remove motion at the spinal segment. Spinal fusion involves setting up a bone graft, as well as possible implanted instruments, to facilitate bone growth across the facet joints. Fusion occurs after the surgery.
• Open Back Surgery – Traditionally, bulging discs are treated with an open back procedure, meaning the surgeon makes a large incision into the skin and cuts muscle and surrounding tissue to gain access to the problematic disc. This traditional surgical option is invasive, requires overnight hospitalization, general anesthesia, and requires a lengthy recovery coupled with strong pain medication.
• Endoscopic Surgery – Fortunately, you have a second option with endoscopic spine surgery. Thanks to the advancement of surgical technology a bulged disc surgery can be performed using endoscopic procedures, meaning the surgeon makes a small incision to insert special surgical tools. During an endoscopic bulging disc operation, the surgeon uses a tiny camera to visualize and gain access to your damaged disc. This minimally invasive new approach offers shorter recovery, easier rehabilitation, and a much higher success rate than open back or neck surgery. A local anesthetic is all that is usually required.
• Percutaneous Endoscopic Discectomy – With the increasing use of endoscopic surgical techniques in spinal surgery, PED was introduced to the treatment of pediatric LDH [Rx]. Two relevant articles published by Mayer et al. [Rx] (4 cases) and Lee et al  (46 cases) were obtained from the literature search. PED was associated with a short-term success rate of 91.3 and 100% respectively, without complications such as leakage of CSF, nerve root injury, interspace infection, etc. The long-term follow-up is yet to be reported. Their recommended indications of PED for pediatric LDH include

Others Treatment

Intradiscal therapy

• Although there are various forms of intradiscal therapy available for adult LDH, similar reports on children and adolescents are comparatively sparse. According to the literature, chemonucleolysis was the only form of intradiscal therapy reported being used on children and adolescents.
• Although FDA approval for chymopapain use in humans has long been withdrawn, it is still being manufactured and in clinical use in Korea, Canada, Australia, UK, and three states in the US [rx]. In comparison with surgery, chemonucleolysis is advantageous in that it is associated with less trauma and post-operative adhesion, shorter hospital stay, earlier remobilization, and lower cost.

Chiropractic Care

• Sixty percent of people with sciatica who didn’t get relief from other therapies and then tried spinal manipulation experienced the same degree of pain relief as patients who eventually had surgery, found a 2010 study in the Journal of Manipulative and Physiological Therapeutics.
• The 120 people in the study saw a chiropractor about 3 times a week for 4 weeks and then continued weekly visits, tapering off treatment as they felt better.
• In people who responded to chiropractic care, benefits lasted up to a year. “spinal manipulations may create a response in the nervous system that relieves pain and restores normal mobility to the injured area,” says study researcher Gordon McMorland, DC, of National Spine Care in Calgary, Alberta. “It also reduces inflammation, creating an environment that promotes the body’s natural healing mechanisms.

Acupuncture

• You can get relief as soon as the first session, though it takes about 12 sessions to see improvement,” says Jingduan Yang, MD, assistant professor at the Jefferson Myrna Brind Center of Integrative Medicine at Thomas Jefferson University. A small study in the Journal of Traditional Chinese Medicine found that of 30 people with sciatica, 17 got complete relief and 10 saw symptoms improve with warming acupuncture, in which the needles are heated.

Yoga

• An ancient Indian practice that aims to improve your body awareness and health. Yoga typically involves getting into various positions or carrying out certain sequences of movements that aim to promote strength and flexibility, body awareness, and a good posture.
• A study in the journal Pain reported that people with chronic back pain who practiced Iyengar yoga for 16 weeks saw pain reduced by 64% and disability by 77%. Although yoga’s effects on sciatica are less clear, gentle forms may be beneficial. By strengthening muscles and improving flexibility, a yoga practice can help sciatica sufferers “move and function better so they don’t fall into a posture that aggravates sciatica.

Massage

• Don’t expect a chilled-out spa massage if you have sciatica. In this instance, trigger-point therapy is best, says Jeff Smoot, vice president of the American Massage Therapy Association. The sciatic nerve sits underneath a muscle called the piriformis, which is located beneath the glutes.
• When the piriformis muscle gets tight, it pinches the sciatic nerve, causing tingling and numbness down into the leg, says Smoot. He applies pressure to irritated and inflamed areas, or trigger points, in the piriformis muscle, as well as in muscles in the lower back and glutes. Typically, Smoot schedules treatments 7 to 10 days apart. If patients don’t see progress by the fourth visit, they need to try another form of therapy, he says.

Topical Preparations

• St. John’s wort oil, a liniment, is “one of my favorites for nerve pain, says Tieraona Low Dog, MD, director of the fellowship at the Arizona Center for Integrative Medicine. Apply the anti-inflammatory oil two or three times a day where there’s pain. Another option: an OTC cayenne pepper plaster or cream; capsaicin, found in chiles, hinders the release of pain-causing compounds from nerves. For severe cases, Low Dog uses the prescription chile patch Qutenza, designed for shingles pain. “One application is effective for weeks,” says Low Dog.

Ice or Heat

• Because the sciatic nerve is buried deep within the buttock and leg, ice or heat on the surface of the body won’t ease that inner inflammation. But the time-honored treatments can act as counterirritants—that is, “they give your body other input in the painful area, and that brings the pain down a notch,” says Ruppert. Apply an ice pack or a heating pad as needed for 15 minutes.

Devil’s Claw

• The herbal medication devil’s claw is “quite a potent anti-inflammatory, working like ibuprofen and similar drugs to inhibit substances that drive inflammation,” says Low Dog. She generally starts patients on 1,500 to 2,000 mg twice a day. Look for a brand that has a standardized extract of roughly 50 mg of harpagoside, the active compound. Safety reviews show that the supplement is well tolerated by most people but should be avoided by patients with peptic ulcers or on blood-thinning medications.

Physiotherapy in PLID 

In stages, 1&2 of PLID physiotherapy must be applied to cure PLID. In the case of stages 3&4, physiotherapy can’t apply due to avoiding another case of foot drop.

Physiotherapy for a lumbar disc bulge

Best Exercises For PLID

Our spinal cord is supported by a number of muscles. Relevant exercises help relieve the pain and reduce the symptoms. Muscle exercises of those muscles associated with the affected area are necessary. Patients must know the region that has a slipped disc and then opt for exercises related to that muscle. The list of best exercises for the slipped disc are mentioned as follows:

• Abdominal Isometrics – It can be performed either on the floor, mat, or bed. This exercise involves moving your lower back towards the surface at which you are performing this exercise. Leg movement must be reduced in this exercise and stomach muscles must be made active. This reduces pain in the lower back because of the attachment of abdominal muscles to the lower side of the vertebral column. Ten repetitions are effective.
• Crunches  – Lie on a flat surface with knees bent. Cross your arm under your head, raise your head and chest in such a manner that your rib cage curl interiorly towards your backbone. Perform this exercise slowly and gradually. In the beginning, perform fewer crunches and repeat it daily and increase the number of turns as you gain strength.
• Lower back extension  – Lie in an upside-down position, raise your upper body with the help of an elbow and hold up yourself in an elevated position for a short span of time, and then slowly lower down. Please make sure that during this exercise you do not raise your pelvis girdle (hip region).
• Bilateral knee to the chest  – Lay down on a flat surface and draw your knee towards your abdominal region, repeat it 5 times, and then switch leg. You can also increase the number of turns each time you repeat it.
• Iso-hip flexion – Lay down over a flat surface and draw your knees towards your chest region in a 90-degree position with your stomach. Place your hands over your knees and then exert your hand pressure to lower your knee. Then utilize the knee pressure to resist the downward movement of your legs, in all both movements should just exert pressure and allow no movements. This position should be maintained for a few seconds and then lowered slowly and gradually.
• Air bike – Sit on a chair with your chest and shoulders supported. Align your knees and feet together and then bring them towards your body and perform a pedaling motion in the air then repeat the same motion while moving your knees farther away from the body. Follow ten repetitions each time and increase its number as you gain strength.
• Hamstring stretch – Lie on a flat surface with your knees bent, place your hands under your knees and then slightly pull your leg towards your chest, repeat it with another leg. This exercise must involve a stretch over the lower thigh muscle.
• Lumbar roll – Lie on a flat surface with your knee bent and your feet lying on the floor then move your legs together towards the right side and then towards your left side. Repeating these movements 5 times on each side.

The above-mentioned best exercises for the slipped disc can be followed but if pain increases or muscle pain is persisting then quit these exercises right away. These exercises not only help in reducing the pain but also activate efficient muscle movement. Along with these exercise tips, proper body postures must be also maintained to prevent further disc damages.

Home Remady for Herniated Disc/Slip Disc

Positioning Yoga( only home practice)

Physiotherapy is a very cheap and good way of getting rid of a herniated disc itself. Therapists will teach you proper exercises and stretches which will improve the disc shape to a great extent. You will notice good differences while performing daily chores after just 4-5 sessions of therapy.

Turmeric

• Turmeric contains curcumin which is a very good anti-oxidant and anti-inflammatory agent. This is why it stops the gel-like fluid inside the discs from coming out and bulge. It also shows antihistamine properties which help to reduce pain because of slowed blood circulation to the area of pain.

Dimethyl Sulfoxide (DMSO)

• Dimethyl sulfoxide is a derivative from sulfur which has antioxidant properties as well as the organic sulfur present in it helps in the growth of new cells and detoxification of the body. The growth of new cells helps to replace the old cells of the discs and prevent the fluid from leaking outside.

Massage With Essential Oils

• Massage with essential oils on the full-body, especially on the spine and lower back regions, will help in good blood circulation and promote the growth of new cells. It will help relieve pain and promote better absorption of oxygen and nutrients. Essential oils will also regenerate the cells of the disc and hence stop the disc from getting slipped.

Acupressure 

• In both techniques, pressure is used for relieving the pain from the swelled area. In acupressure fingers, hips and elbows are used and acupuncture needles are used. But this should be done with the help of an experienced practitioner and not alone. This is not recommended for patients having high blood pressure and for women who are pregnant.

 TENS

• TENS stands for Transcutaneous Electrical Nerve Stimulation and this is one of the best remedies for a herniated disc at home. This treatment uses a low voltage electric current which is applied to the affected area and helps the body to release endorphin which decreases the pain.

Cayenne Pepper

•  It is a very effective ingredient for the treatment of herniated discs. You can drink its tea or make a paste of the pepper using water and apply it to the affected area.

Diet

• Diet is necessary to keep away all types of bad conditions that might affect you. Drink a lot of water and eat a balanced diet. Take excess of fibers and proteins. During this condition, you should avoid dairy products and red meat. Also, avoid fat-free foods.

 Epsom Salt

• Epsom salt is one of the widely used natural painkillers and anti-inflammatory agents. You can use this by adding 3-4 cups of salt in a hot water bath. Stay inside the bath for 15 minutes. It will help you achieve maximum relaxation. Do not use this remedy if you are diabetic or pregnant. If you are on any type of medication consult your doctor before bathing in Epsom salt.

 Horsetail

• Horsetail is a herb that has high quantities of minerals in it. It nourishes our tissues and has the ability to heal broken bones and torn ligaments. All you need to do is add some horsetail leaves to half a liter of water. Boil on low heat till the water quantity reduces to half its quantity. Cool the solution and filter it off. You can drink 5 ml of the solution thrice a day. It will heal herniated disc very fast.

California Poppy

• California poppy is anti-inflammatory and analgesic in nature. This is what makes it a good treatment for a herniated disc. You can tear the leaves of the California poppy into small pieces and make a paste out of it using water. Use little hot water so that when you apply the paste to the affected area it is still warm.

 White Willow Bark

• White willow bark is used for reducing the discomfort of herniated discs. The chemical structure of these drugs shows a marked similarity to aspirin hence acts as an analgesic but doesn’t irritate your gut. It is also astringent and anti-inflammatory in nature. This herb might react with drugs hence do consult your doctor if you are on any kind of medication.

Comfrey Leaves

• Comfrey leaves have the power to heal bones and connective tissues of the body. All you need to do is take some fresh leaves and add them to cold water. Let it remain undisturbed for around 12 hours. After 12 hours heat the above solution and filter it. Add the filtrate to bathwater and take a bath in it 2 times a day. Do not consume it orally because it contains hepatic-toxin alkaloids.

Boswellia

• Boswellia is a naturally occurring painkiller that is a very effective remedy for a herniated disc. All you can do is make a decoction of Boswellia and consume it 2 times a day to reduce pain and discomfort associated with herniated discs. Boswellia is an organic painkiller that effectively treats the problem of a herniated disc. It is also an herbal cure for osteoarthritis.

Omega-3 Fatty Acids

• Omega-3 Fatty acids are helpful in decreasing the inflammation and pain experienced due to herniated disc disorder. This acid forms the collagen which is used by the broken discs for repairing itself. Eat foods that are high in this kind of fat like fish, almonds, sprouts, and walnuts.

Colchicine

• Colchicine is an active amino-alkaloid found in the plant of Kurchi or autumn crocus. This powder is obtained by crushing the seeds of the plant. It has anti-inflammatory properties that are effective against the slipped disc. Make a paste with kurchi powder and honey and consume it once a day. You can also make tea out of the powder or mix the powder in milk and have it once or twice a day.

Burdock

• Burdock contains a lot of anti-oxidants which is helpful to detoxify the body and remove all kinds of harmful substances and decrease the pain and inflammation in your body. It also treats arthritis. Burdock can be consumed as a decoction once or twice a day.

Passionflower

• Passionflower is helpful for slipped discs because the essential oils present is antispasmodic in nature. It reduces pain and inflammation. You can massage with passionflower essential oil or take capsules made from it, however, do consult your doctor before taking capsules.

Homeopathy For PLID & Back Pain

Primary Remedies

• Aesculus – Pain in the very low back (the sacral or sacroiliac areas) that feels worse when standing up from a sitting position, and worse from stooping, may be eased with this remedy. Aesculus is especially indicated for people with low back pain who also have a tendency toward venous congestion and hemorrhoids.
• Arnica montana – This remedy relieves lower back aches and stiffness from overexertion or minor trauma.
• Bryonia – This remedy is indicated when back pain is worse from even the slightest motion. Changing position, coughing, turning, or walking may bring on sharp, excruciating pain. This remedy can be helpful for back pain after injury and backaches during illness.
• Calcarea carbonica – This is often useful for low back pain and muscle weakness, especially in a person who is chilly, flabby or overweight, and easily tired by exertion. Chronic low back pain and muscle weakness may lead to inflammation and soreness that are aggravated by dampness and cold.
• Calcarea phosphorica – Stiffness and soreness of the spinal muscles and joints, especially in the neck and upper back, may be relieved by this remedy. The person feels worse from drafts and cold, as well as from exertion. Aching in the bones and feelings of weariness and dissatisfaction are often seen in people who need this remedy.
• Natrum muriaticum – Back pain that improves from lying on something hard or pressing a hard object (such as a block or book) against the painful area suggests a need for this remedy. The person often seems reserved or formal but has strong emotions that are kept from others. Back pain from suppressed emotions, especially hurt or anger may respond to Natrum muriaticum.
• Nux vomica – This remedy is indicated for muscle cramps or constricting pains in the back. Discomfort is made worse by cold and relieved by warmth. The pain usually is worse at night, and the person may have to sit up in bed to turn over. Backache is also worse during constipation, and the pain is aggravated when the person feels the urge to move the bowels.
• Rhus Toxicodendron – This remedy can be useful for pain in the neck and shoulders as well as the lower back when the pain is worse on initial movement and improves with continued motion. Even though in pain, the person finds it hard to lie down or stay still for very long, and often restlessly paces about. Aching and stiffness are aggravated in cold damp weather and relieved by warm applications, baths or showers, and massage.
• Sulfur – This remedy is often indicated when a person with back pain has a slouching posture. The back is weak and the person feels much worse from standing up for any length of time. Pain is also worse from stooping. Warmth may aggravate the pain and inflammation.

Additional Tips

• If you are overweight, try to lose some pounds.
• Exercise every day.
• Lift things in a proper way, as guided by a therapist. Do not lift heavyweights.
• Stop smoking and drinking.
• Always make sure you are in the right posture whatever activity you may be doing.
• Wear flat and soft shoes. Avoid heels.
• Walk and move around cautiously.

Slipped discs can be really painful but with the right treatment and precautions, you can become as fit as you were before. So start taking home remedies and consult a doctor whenever you feel any kind of severe pain.

Reference

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