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Lower back and leg painLower back and leg pain
Bao HengBao Heng
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Lumbar disc herniationLumbar disc herniation
Lumbar spinal stenosisLumbar spinal stenosis
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Lumbar disc herniationLumbar disc herniation
Anatomy Anatomy
Clinical featuresClinical featuresRadiological examRadiological exam
Differential diagnosisDifferential diagnosisTreatmentTreatment
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Anatomy Anatomy
Intervertebral discIntervertebral disc
1.1. Annulus fibrosus Annulus fibrosus
2.2. Nucleus pulposusNucleus pulposus
3.3. End plateEnd plate
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Anulus fibrosus Anulus fibrosus
Anulus fibrosus makes up peripheralAnulus fibrosus makes up peripheral
portion of disk structureportion of disk structure
Composed of fibrocartilage and type IComposed of fibrocartilage and type I
collagencollagen
Anulus is wider anteriorly than posteriorlyAnulus is wider anteriorly than posteriorly
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Nucleus pulposusNucleus pulposus
Nucleus pulposus consists of a network of Nucleus pulposus consists of a network of
delicate collagenous fibers in a mucoprotein geldelicate collagenous fibers in a mucoprotein gel
Nucleus has a high water content,apparentlyNucleus has a high water content,apparentlythe result of imbibition by the gel;the result of imbibition by the gel;
It functions to resist compressive loads;It functions to resist compressive loads;
water content declines with advancing agewater content declines with advancing age
Gradual loss of proteoglycan content explainsGradual loss of proteoglycan content explains
the loss of water w/ agingthe loss of water w/ aging
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Disc pressure / failureDisc pressure / failure
Intradiscal pressure is higher when sittingIntradiscal pressure is higher when sittingthan when standing; - sitting-leaningthan when standing; - sitting-leaningforward > sitting > standing > lying on sideforward > sitting > standing > lying on side
> supine;> supine;Rotation combined w/ flexion are the worstRotation combined w/ flexion are the worst
positions for disc injury;positions for disc injury; It is elevated by bending forward, bendingIt is elevated by bending forward, bending
to side, lifting, coughing, sneezing, andto side, lifting, coughing, sneezing, andstraining;straining;Asymmetric & cyclic loading combined w/Asymmetric & cyclic loading combined w/
lateral bend, compression, and flexion arelateral bend, compression, and flexion arerisk factors for disk herniation;risk factors for disk herniation;
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Sciatic nerveSciatic nerve
Anterior branchs of L4,L5,S1-3 Anterior branchs of L4,L5,S1-3
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L4 rootL4 root
••Foot inversion (tibialis anterior m.)Foot inversion (tibialis anterior m.)
••Patellar reflexPatellar reflex
••Medial aspect of foot sensationMedial aspect of foot sensation
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L5 rootL5 root
••Great toe extension (extensor hallicusGreat toe extension (extensor hallicus
longus m.)longus m.)
••No reflexNo reflex
••Dorsum (top) of foot sensationDorsum (top) of foot sensation
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S1 rootS1 root
••Foot eversion (peroneus longus m.)Foot eversion (peroneus longus m.)
••Achilles tendon reflexAchilles tendon reflex
••Lateral foot sensationLateral foot sensation
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Posterolateral disc herniationPosterolateral disc herniation
Protruded disc usuallyProtruded disc usuallycompresses next lower nerve ascompresses next lower nerve asthat nerve crosses level of discthat nerve crosses level of disc
in its path to its foramenin its path to its foramen
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Central (posterior) herniationCentral (posterior) herniation
In the lower lumbar segments, centralIn the lower lumbar segments, central
herniation may result in S1 radiculopathyherniation may result in S1 radiculopathy
Cauda equina syndromeCauda equina syndrome
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Far lateral disc herniationFar lateral disc herniation
Compress the nerve root above the level of theCompress the nerve root above the level of theherniation (hence a L4-L5 far lateral herniationherniation (hence a L4-L5 far lateral herniation
may result in a L4 radiculopathy)may result in a L4 radiculopathy)Occurs in 6-10% of all lumbar disc herniations;Occurs in 6-10% of all lumbar disc herniations;
L4 nerve root is most often involved;L4 nerve root is most often involved; Patient typically have intense radicular painPatient typically have intense radicular pain
(sciatic 25% and femoral 75% of the time)(sciatic 25% and femoral 75% of the time)
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Far lateral disc herniationFar lateral disc herniation
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Symptoms and signs
Low back pain with radiation of
severe pain down the back of the
leg to the ankle and foot.
Neurological signs such as motor
and sensory loss and occasionally
bladder involvement.
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Spasm of the spinal muscles with
tenderness over the lower lumbar
spine on the side of the lesion.The muscular spasm may produce a
scoliosis.
There may be a history of previous
episodes of back pain and sciaticaor of a previous injury.
P t i f th L4/5
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Protrusion of the L4/5
disc
Protrusion of the L4/5 disc may cause L5
root pressure with pain radiating down the
leg to the dorsum of the foot.
Numbness on the outer side of the calf andmedial two-thirds of the dorsum of the
foot
Weakness of dorsiflexion, particularly
of the foot and toes.
P t i f th
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Protrusion of the
L5/S1
The S1 nerve root is compressed
Pain and numbness on the outer side ofthe foot and under side of the heel.
Weakness of both eversion and
antarflexion of the foot
The ankle jerk is diminished or absent
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Protrusion of the L3/4
Protrusion of the L3/4 disc may
cause pressure on the L4 nerve root
Numbness over the front of the kneeand leg
The knee jerk is diminished.
Weakness of the knee extensors.
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Central protrusion
Central protrusion of a lower lumbar disc
can press on the cauda equina and lead to
urinary retention.
On examination there is usually perianal
numbness and a patulous anus.
Emergency decompression is essential to avoid
permanent damage to sphincter innervation.
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Cauda equinaCauda equina
The spinal cord ends in the lumbar area andThe spinal cord ends in the lumbar area and
continues through the vertebral canal ascontinues through the vertebral canal as
spinal nerves. Because of its resemblancespinal nerves. Because of its resemblance
to a horse's tail, the collection of theseto a horse's tail, the collection of these
nerves at the end of the spinal cord isnerves at the end of the spinal cord is
called the cauda equina. These nerves sendcalled the cauda equina. These nerves send
and receive messages to and from theand receive messages to and from the
lower limbs and pelvic organs.lower limbs and pelvic organs.
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Limitation of lateral flexion of the
lumbar spine to the same side will be
most marked with a protrusion lateral
to the nerve root
while limitation of lateral flexion to
the opposite side will be most marked
with a protrusion medial to the nerve
root.
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Straight Leg RaiseStraight Leg Raise
In a normal person, this can be done toIn a normal person, this can be done to
about 75 or 80 degrees of flexion at theabout 75 or 80 degrees of flexion at the
hip without sharp pain radiates down tohip without sharp pain radiates down tothe leg.the leg.
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Well leg or cross leg sign: if there is a leftWell leg or cross leg sign: if there is a left
sided herniation, raising the right leg maysided herniation, raising the right leg may
cause pain to shoot down the course of thecause pain to shoot down the course of theleft sciatic nerve.left sciatic nerve.
Sciatic stretch test: this test is performedSciatic stretch test: this test is performed
after a straight leg raising test by lowering theafter a straight leg raising test by lowering the
affecting leg a few degrees belowaffecting leg a few degrees belowthe point .the point .
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RadiographsRadiographs
Traction spursTraction spurs
Disc space narrowingDisc space narrowing
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C TC T
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MRIMRI
There is a 29% prevalence of discThere is a 29% prevalence of disc
herniation in asymtomatic individualsherniation in asymtomatic individuals
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MRIMRI
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Differential diagnosis
Secondary tumours and
multiple myeloma of the
lumbar spine which usuallycause vertebral destruction
with sparing of the discs.
Fractures and infections
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Natural HistoryNatural History
Prognosis of disc herniation is generallyPrognosis of disc herniation is generally
good regardless of treatment;good regardless of treatment;
Patients operated on for proven discPatients operated on for proven disc
herniations improved more rapidly thanherniations improved more rapidly than
patients treated non operatively;patients treated non operatively;
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Natural HistoryNatural History
Within 4-5 years both operative andWithin 4-5 years both operative and
non operative treatment groups willnon operative treatment groups will
generally have comprable neurologicgenerally have comprable neurologicrecovery; hence long term resultsrecovery; hence long term results
are similar w/ or w/o surgery;are similar w/ or w/o surgery;
Of all patients who sustain acuteOf all patients who sustain acutesciatica, less than 25% will requiresciatica, less than 25% will require
surgery;surgery;
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TreatmentTreatment
Nonoperative treatmentNonoperative treatment
Pain relief is best achievedPain relief is best achievedby immobilizing the spine andby immobilizing the spine and
strengthening the back musclesstrengthening the back muscles
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Nonoperative treatment
Bed rest
Nonsteroidal anti-inflammatory
agentsActive physical therapy
Skin traction for sciatic irratation
Epidural steroid injection
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Epidural abscess
Male, 43 yrs , fever ,painMale, 43 yrs , fever ,pain After Epidural steroid injectionAfter Epidural steroid injection
compulsive positioncompulsive position Abscess
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SurgerySurgery
Opened surgeryOpened surgery
Minimally invasive surgeryMinimally invasive surgery
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ComplicationsComplications
InfectionsInfections
RecurrenceRecurrence
InstabilityInstability
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Postoperative discitisPostoperative discitis
Preoperative
postoperative
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Lumbar instabilityLumbar instability
10 years after surgery10 years after surgery
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Lumbar stenosisLumbar stenosis
Spinal stensosis is a narrowing of theSpinal stensosis is a narrowing of the
spinal canal or neural foramina producingspinal canal or neural foramina producing
root ischemia and neurogenic claudicationroot ischemia and neurogenic claudication
Although degenerative spondylolisthesisAlthough degenerative spondylolisthesis
is common cause of stenosis, 10% of is common cause of stenosis, 10% of
adults > 65 yrs may have this finding &adults > 65 yrs may have this finding &many are asymptomatic;many are asymptomatic;
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Clinical FindingsClinical Findings
Patients are usually 60 years or older;Patients are usually 60 years or older; Unilateral or bilateral leg pain, w/ or Unilateral or bilateral leg pain, w/ or
without back pain;without back pain;
Pain occurs when the patient is uprightPain occurs when the patient is uprightand particularly when walkingand particularly when walking
Typical symptom is leg pain, numbness,Typical symptom is leg pain, numbness,and weakness developing after patientand weakness developing after patient
walks a predictable distance; - patientwalks a predictable distance; - patientseeks relief by sitting, leaning forward toseeks relief by sitting, leaning forward to"relieve pressure"relieve pressure
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Phalen testPhalen test
With patient upright, bend the patient intoWith patient upright, bend the patient into
extension for a full minuteextension for a full minute
This should accentuate the spinal stenosis;This should accentuate the spinal stenosis;
Positive test will produce a crescendo of legPositive test will produce a crescendo of leg
symptoms followed by rapid relief of thesesymptoms followed by rapid relief of these
symptoms when the patient flexes forward,symptoms when the patient flexes forward,
places his hands on examinationplaces his hands on examinationtable, and places one foot on stooltable, and places one foot on stool
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CT scan:CT scan:
Evaluate for lateral stenosis & centralEvaluate for lateral stenosis & central
stenosisstenosis
Dural sac w/ AP diameter of < tenDural sac w/ AP diameter of < ten
millimeters is consistent w/ clinicalmillimeters is consistent w/ clinical
syndrome of lumbar stenosis;syndrome of lumbar stenosis;
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Surgical TreatmentSurgical Treatment
DecompressionDecompression
Laminae are minimally trimmed for Laminae are minimally trimmed for
exposure;exposure; Includes widening of lateral recess;Includes widening of lateral recess;
Removal of medial rim of facetsRemoval of medial rim of facets
Adult DegenerativeAdult Degenerative
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gg
SpondylolisthesisSpondylolisthesis
Often occurs as a result of degenerativeOften occurs as a result of degenerativedisc disease and facet deficiency;disc disease and facet deficiency;
It is often associated w/ intersegmentalIt is often associated w/ intersegmental
instability and w/ central stenosis;instability and w/ central stenosis; Involves L4-L5 level four times more oftenInvolves L4-L5 level four times more often
than the L5/S1 level;than the L5/S1 level;Often causes radiculopathy related toOften causes radiculopathy related to
nerve compression within the foramen (ie,nerve compression within the foramen (ie,L4/L5 spondylithesis will cause a L4L4/L5 spondylithesis will cause a L4radiculopathy)radiculopathy)
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Dynamic radiographsDynamic radiographs
Flexion-Extension X-raysFlexion-Extension X-rays
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Non Operative TreatmentNon Operative Treatment
NSAIDSNSAIDS
Epidural steroidsEpidural steroids
BracingBracing
Change of job typeChange of job type
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SurgerySurgery
Decompression of the nerve rootsDecompression of the nerve roots
Stabilization by posterolateral fusionStabilization by posterolateral fusion
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