Lumbar Degenerative Disk Disease Clinical Presentation
- Author: Rajeev K Patel, MD; Chief Editor: Stephen Kishner, MD, MHA more...
The patient's history is an extremely valuable tool for identifying the intervertebral disk as the nociceptive source. Classic historic features are associated with a diskogenic etiology of mechanical low lumbar complaints. The clinician must ask several key questions to elicit the information necessary for correct diagnosis. These questions address events that cause the symptoms, the location and nature of the symptoms, any exacerbating and mitigating factors or positions, and the patients' medical and surgical history. Often, a nociceptive source of back pain is not found.
- Patients with diskogenic pain typically describe an inciting traumatic event resulting in sudden forced flexion and/or rotational moment; however, some patients describe a spontaneous onset of symptoms.
- Symptoms, usually isolated in the low lumbar region and buttocks, can vary, with referral to the lower thoracic and/or upper lumbar region, abdomen, flanks, groin, genitals, thighs, knees, calves, ankles, feet, and toes.
- Classic diskogenic pain is exacerbated by activities that load the disk, such as sitting, arising from a seated position, awaking in the morning, lumbar flexion with and without rotation/twisting, lifting, vibration (eg, riding in a car), coughing, sneezing, laughing, and the Valsalva maneuver.
- Symptoms are mitigated by lying on the side with hips and knees flexed (fetal position), by changing positions frequently, and/or by engaging in activity.
- Diskogenic pain is usually described as aching; however, a wide spectrum of adjectives can be reported from soreness to stabbing pain.
- Patients with a surgical history of lumbar arthrodesis, lumbar diskectomy, or lumbar laminectomy have changes in lumbar spine biomechanics resulting in susceptibility to diskogenic disease.
- The patient's medical history should be investigated with specific inquiry directed toward a personal history of cancer, arthritis, or infection or systemic disease that could increase risk of infection.
- The review of systems should include assessments for fever, incontinence, symptoms suggestive of metastasis or metabolic disease, and psychological issues including depression and drug use or abuse.
Physical examination is an important adjunct to history in determining diskogenic etiology of symptoms, beginning with the first view of the patient in the examination room. The patient may prefer to stand, pace, or sit in a reclining position since these positions usually alleviate symptoms of diskogenic etiology.
- Note the patient's height and weight, as obesity may produce excess load to the low lumbar intervertebral disks.
- Inspection of the low lumbar region is important since this part of the examination may offer a clue to history of lumbar surgery if a scar exists. Inspection while the patient is standing and during forward flexion and extension may reveal a kyphotic or scoliotic deformity. Inspection and palpatory examination should be performed in flexion with the patient standing and seated to determine whether the pain source is in the pelvis or sacral area.
- Palpation of the lumbar paraspinals and spine stabilizers may elicit tenderness, as these muscles may be tight, have active or latent trigger or tender points, or be in reactive muscle spasm.
- A step deformity, in which the spinous process of the segment involved protrudes ventrally, may exist as a consequence of spondylolisthesis.
- Measure the lower extremity circumference at mid thigh and mid calf at the same time of day so comparable results are obtained; they should be symmetric. Hips, knees, and ankles should have full range of motion (ROM), without crepitus or effusions.
- Diskogenic stress maneuvers usually reproduce the patient's low lumbar and buttock symptoms. These maneuvers include pelvic rocking and sustained hip flexion.
- Perform pelvic rocking with the patient in a supine position. Flex the patient's hips until the flexed knees approximate to the chest; then, rotate the lower extremities from one side to the other.
- Perform sustained hip flexion with the patient supine; raise the patient's extended lower extremities to approximately 60° in relation to the examination table. Then ask the patient to hold the lower extremities in that position and release. Query the patient regarding reproduction of low lumbar and/or buttock pain. Then lower the extremities successively approximately 15°, and, at each point, note the reproduction and intensity of pain. The test is positive if the patient complains of low lumbar and/or buttock pain of increasing intensity as the extremities are lowered at successive angles. Sacroiliac joint stress maneuvers do not provoke pain. Root tension signs are negative.
- Orientation, mood, and affect usually are within normal limits, and excessive emotional lability may be a sign of nonorganic pathology. These provocative maneuvers should not be accompanied by exorbitant demonstrations of perceived pain. Such overt pain behavior should alert the clinician to important psychosocial issues.
- Normal neurologic examination, with intact pinprick sensation throughout all dermatomes, full muscle strength throughout all myotomes, and symmetric muscle stretch reflexes, are associated with diskogenic disease. Two muscles should be tested with reflexes elicited representing each lumbar root; this test helps determine whether the problem is root pathology or a focal neuropathy; the straight leg test also should be performed in supine and seated positions.
- Gait usually is normal.
- Lumbar ROM usually is limited and painful, chiefly into flexion; however, extension also can be restricted and painful. Lumbar ROM should be assessed in flexion, extension, lateral bending, and rotation. A careful, systematic, and thorough structural examination should be performed to assess for subtle abnormal findings that may be amenable to manual therapy or manipulation.
The cause of LDDD is unknown. Several theories cite traumatically induced acute annular tear as the inciting pathologic event. Other theories suggest that degeneration of the lumbar disk is a natural part of aging; however, these theories do not explain spontaneously occurring annular tears and disk degeneration in the young. Therefore, the cause of LDDD is most likely multifactorial. Various genetic, environmental, autoimmune, inflammatory, traumatic, infectious, toxin-induced, and other factors, alone or in various combinations, may result in initiation and progression of degeneration of the lumbar disks in a way that has not been elucidated.
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