Herniated Nucleus Pulposus Clinical Presentation

Updated: May 20, 2019
  • Author: Deepak Gautam, MBBS, MS(Orth); Chief Editor: Jeffrey A Goldstein, MD  more...
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Presentation

History

The importance of history-taking as the first integral step in the evaluation of a patient suspected of having a herniated disk cannot be overstated. 

Many of these patients narrate a history of some sort of prodromal back pain. They may correlate their symptoms with an episode of trauma, which, more often than not, is incidental and not associated with the pathology. However, certain typical physical activities that the patient claims to have preceded their symptoms may be of importance and may lead the clinician toward the diagnosis of a herniated disk. These include sudden twists or jerks, lifiting heavy weights, and falls. 

Pain is usually the chief complaint; it may be axial or, more typically, radicular. It is important to ask the patient several questions regarding their pain, such as the following:

  • Is it predominantly back pain or leg pain?
  • What is the character of the pain?
  • Is the onset of pain acute, subacute, or chronic?
  • Is the pain aggravated by any activity or maneuver?
  • Is the pain relieved by a particular posture or maneuver?
  • Was there any previous history of similar symptoms, and if so, how were the symptoms treated?

Red-flag signs (eg, a concomitant history of fever and weight loss, unrelenting night pain, long-term oral steroid or immunosuppresant use, or a history or suspicion of cancer, particularly in patients older than 50 years) may indicate a more serious underlying pathology and should be promptly investigated. Apart from pain, pertinent questions related to the symptoms of motor weakness, sensory disturbances, and bladder or bowel dysfunction should be asked.  A progressive neurologic deficit or cauda equina syndrome is considered a surgical emergency because irreversible consequences may result if these are left untreated.

Risk factors such as the patient's lifestyle—for example, if it involves prolonged sitting and bending forward, a history of smoking, or a history of antidepressant use—should also be addressed. Pain in disk herniation often has a psychosocial component, particularly when the symptoms do not follow a fixed dermatomal or myotomal pattern and do not correlate with the imaging findings. Thus, the clinician must also direct history-taking towards this important aspect. 

Obtaining a thorough history of activity intolerance requires some time and attention to the details of specific examples and the positions or actions that cause problems. Also, it is helpful to determine which activities the patient is unable or less able to perform and which activities exacerbate or moderate the pain. An assessment of the physical demands of the patient's occupation and daily activities provides the perspective for the described activity intolerance. A pain drawing can be very helpful in assessing the pattern of pain (eg, a dermatomal distribution) or in assessing the organicity of the complaints.

Next:

Physical Examination

In the physical examination, the first indication that a patient may have a lumbar disk herniation comes from the patient's gait itself as he or she walks into the examination room. A characteristic feature is a sciatic list, which represents an attempt to relieve the neuromeningeal tension by drawing the nerve root away from the herniated disk. A disk herniation lateral to the nerve root ( a "shoulder disk") causes the patient to lean away from the side of the herniation, whereas a herniation medial to the nerve root (an "axillary disk") causes the patient to lean towards the side of the herniation. There may be paraspinal muscle spasm, as indicated by obliteration of the central furrow. 

Numerous examination maneuvers (eg, Lasegue classic test, Lasegue rebound sign, Lasegue differential sign, Braggard sign, flip sign, Deyerle sign, Mendel-Bechterew sign, well-leg test or Fajersztajn sign, both-legs or Milgram test) are available but they cloud the issue, in that the sciatic nerve-root tension or straight-leg raising test (SLRT) is the basis for nearly all of them. They are essentially modifications for subtle differences, but the provocation of radiating pain down the leg is of a neural compressive lesion and compression of the sciatic nerve root, if it goes below the knee. Furthermore, the provocation of radiating pain down the leg is the most sensitive test for a lumbar disk herniation.

The SLRT should always be performed bilaterally. The test is considered positive if sciatic pain is reproduced between 30º and 70º of elevation. Studies have determined that in the first 35º of elevation, the slack in the nerves is taken up, and at 35º or more, tension is placed on the nerves. More than 70º of elevation causes no further stretch of the nerve roots. The SLRT is best for eliciting L4, L5, or S1 radiculopathy.

For a higher lumbar lesion, reverse straight-leg raising or hip extension that stretches the femoral nerve is analogous to an SLRT. The Spurling test in the cervical spine is used to detect foraminal stenosis (the Kemp test is used in the lumbar region) rather than specifically for intervertebral disk herniation or nerve root tension. Careful hip, rectal, and genitourinary examinations help exclude complications of those organ systems in the diagnosis of higher lumbar lesions.

A meticulous neurologic examination must follow inspection, palpation, and examination maneuvres. One must know the dermatomal patterns of the commonly afflicted nerve roots (L4, L5, and S1). The examiner should be wary of the presence of a glove-and-stocking distribution sensory loss, which can indicate a peripheral neuropathy, such as may be associated with diabetes, or functional overlay; this is not anatomic. Standard Medical Research Council (MRC) grading is used to grade muscle power during motor examination. Upper-motor-neuron signs can be elicited if a cervical disk herniation is causing cord compression.

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