Lumbar (Intervertebral) Disk Disorders Clinical Presentation
- Author: Jere F Baldwin, MD; Chief Editor: Rick Kulkarni, MD more...
History
The history may be sufficient to make presumptive diagnosis of a disk disorder, or it may guide the physician's usage of ancillary testing and consultations to further differentiate both the specific type of disk disease and potential other etiologies of the patient's back pain.
Patients with disk disease usually are not able to give a precise time that the problem began because it usually is preceded by multiple episodes of less severe low back pain.
Asking the patient the location of the pain is important. Pain that is localized to the lower back and gluteal area often is associated with disk disease. Pain associated with nerve root involvement commonly radiates down the leg, particularly below the level of the knee.
Ask the patient about any unusual recent activity, especially if it involved the patient remaining in a flexed or rotated position. Find out if the patient experienced any recent trauma. Pain with flexion, rotation, or prolonged sitting or standing, and sharp (rather than dull) pain are suggestive of disk disease.
The onset of pain may begin suddenly[1] or gradually after injury. Typically, the pain is located bilaterally at the posterior belt line. The pain pattern usually is referred rather than radicular. Back motion, which includes sitting, standing, lifting, bending, and twisting, usually aggravates the pain; it often is relieved with rest and a recumbent position.
Physical
Nerve roots exit the spine below the intervertebral disks; thus, herniation of a disk involves the nerve root below it.
Observe the patient for abnormal gait, which is suggestive of a loss of the normal rhythm. Have ambulatory patients walk on their toes to test the function of S1.
Observe the patient for abnormal posture, which is suggestive of splinting or guarding from pain.
Test the patient's ability to dorsiflex the foot while sitting to test the L5 nerve root. Test for sensory loss that corresponds to a dermatomal area.
Palpation of the lumbar spine and lower back is not helpful in the diagnosis of disk disease, but it should be done to rule out other causes of low back pain.
A positive straight leg raising test is indicative of nerve root involvement. This test is performed while the patient is lying supine with one leg either straight or flexed at the knee, with the sole of the foot flat on the stretcher. The other leg is kept straight and lifted by the examiner. If pain occurs when the leg is lifted between 30-70 degrees from horizontal and travels down the leg until below the knee, the test is positive.
Nerve root stretch test results are often negative.
Patients may exhibit decreased lumbar range of motion (ROM).
The usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate) should be performed.
A careful abdominal and vascular examination is mandatory in evaluation of these patients.
Causes
The normal aging process of the musculoskeletal system aggravates acute events.
Risk factors include the following:
- Age
- Activity
- Smoking
- Vibration (eg, driving a car)
- Sedentary lifestyle
- Psychosocial factors
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