Lumbar Disc Herniation

Picture
Symptoms of lumbar disc herniation can sometimes mimic those of SI joint dysfunction.  Similar patterns of symptoms can be present.  However, there are defining characteristics of each help to differentiate between them.  Disk herniations occur when there is a change in shape of the annulus fibrosis, causing it to protrude outside of its usual border and toward the vertebral canal.  In severe cases, the annulus fibrosis can rupture allowing nuclear material into the vertebral canal.  This can result in impingement of the spinal nerve roots causing irritation.  Ruptures most often occur just lateral to the posterior midline of the disc giving rise to unilateral symptoms.  Larger bulges or lesions can result in bilateral symptoms.
  • Typical age of onset 20-40
  • Mechanism of injury may be insidious or sudden onset (such as bending down to lift an object)

Clinical Signs & Symptoms

  • Low back pain, symptoms often increasing with sneeze or cough
  • Restricted lumbar spine ROM
  • Increased pain in sitting (lumbar flexion activities)
  • Decreased pain in supine (extension activities)
  • Radiating pain into the lower extremity            
  • Paresthesia, usually unilateral
  • Hyporeflexia/weakness on affected side
  • Symptoms worse in the morning secondary to rehydration of disc causing protrusion to enlarge


Neurological and Special Testing

  • Dermatomes (sensation typically not affected)
  • Myotome testing (weakness may be noted in ankle dorsiflexion)
  • Deep tendon reflexes (knee – L3/4, extensor hallicus longus – L5, achilles – S1-S2).  May be hyporeflexive depending on level of lesion           
  • Straight Leg Raise test – should be positive in provoking symptoms in the LE associated with the side of the impingement


Lumbar Spinal Stenosis

Picture
Spinal stenosis can either be acquired or congenital.  Acquired stenosis is much more common and is a degenerative condition.  Spinal stenosis refers to a narrowing of the spinal canal and/or the intervertebral foramina causing compression of the spinal cord or the nerve roots as they exit through the intervertebral foramina.  Patients will most often present with a flexed posture which allows for decompression of the articular facets and provides more room for the neural structures.  Symptoms are often bilateral in nature.  Impingement often involves multiple spinal segments.
  • Typical age of onset >50
  • Onset is insidious in nature   


Clinical Signs & Symptoms

  • Bilateral low back pain
  • Radiating bilateral leg pain
  • Restricted lumbar spine ROM
  • Increased pain with extension activities such as standing and walking (especially uphill)
  • Decreased pain with flexion activities such as sitting and bending forward
  • Bilateral paresthesias
  • Shopping cart sign (decreased pain when walking in a flexed posture)

Neurological and Special Testing

  • Dermatomes - light touch sensation expected to be decreased on the outer leg, first three toes, and medial side of the foot with an L4-5 pattern
  • Myotomes - ankle dorsiflexion and extensor hallicus longus are expected to be weak given an L4-5 level impingement
  • Deep tendon reflexes - (knee – L3/4, extensor hallicus longus – L5, achilles – S1-S2).  May be hyporeflexive depending on level of lesion           
  • Straight Leg Raise – may demonstrate a positive sign, however, they are less common with spinal stenosis than with disc herniation