Lumbar Disc Prolapse

CLINICAL FEATURES (contd)

'mechanical' signs: Spinal movements are restricted, scoliosis is often present and is related to spasm of the erector spinae muscles, and the normal lumbar lordosis is lost.

Straight leg raising: L5 and SI root compression causes limitation to less than 60 from the horizontal and produces pain down the back of the leg. Dorsiflexion of the foot while the leg is elevated aggravates the pain. Elevation of the 'good' leg may produce pain in the other leg.

(If in doubt about the veracity of a restricted straight leg raising deficit, sit the patient up on the examination couch with the legs straight. This is equivalent to 90° straight leg raising.)

Reverse leg raising (femoral stretch) Tests for irritation of higher nerve roots (L4 and above)

NEUROLOGICAL DEFICIT: Depends on the predominant root involved:

L4 -Quadriceps wasting and weakness; sensory impairment over medial calf; impaired knee jerk. L5 -Wasting and weakness of dorsiflexors of foot, extensor digitorum longus and extensor hallucis longus; wasting of extensor digitorum brevis; sensory impairment over lateral calf and dorsum of foot. SI - Wasting and weakness of plantar flexors; sensory impairment over lateral aspect of foot and sole; impaired ankle jerk.

Root signs cannot reliably localise the level of disc protrusion due to variability of the anatomical distribution.

Central disc protrusion

Symptoms and signs of central disc protrusion are usually bilateral, although one side is often worse than the other.

Leg pain: Extends bilaterally down the back of the thighs. Pain may disappear with the onset of paralysis.

Paraesthesia: Occurs in the same distribution.

Sphincter paralysis: Loss of bladder and urethral sensation with intermittent or complete retention of urine occurs in most patients. Anal sensation is usually impaired and accompanies constipation.

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