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- nucleus pulposus squeezes through annulus fibrosus
- bulges posteriorly or posterolaterally
- beneath posterior longitudinal ligament
- + local oedema
- cause pressure on nerve roots
Symptoms
- depend on part and degree of compression
- usually fit young adult
- while lifting / stooping / coughing → backache
- then or 1-2 days later
- sciatica
- numbness
- paraesthesia
- muscle weakness
- made worse by coughing or straining
- cauda equina compression may cause urinary retention
Signs
- stands with slight list to one side
- if disc medial to nerve root then towards affected side
- if disc far lateral then away
- all back movements severely limited
- tenderness in middle of low back
- paravertebral muscle spasm
- straight leg raising painful and limited on affected side
- <50º
- reproduces radicular symptoms
- dorsiflexion of foot and bowstringing of lateral popliteal nerve
Neurological Exam
- weakness
- diminished reflexes
- senosry loss
- L5
- weakness of big toes extension
- knee flexion
- sensory loss on outer side of leg and dorsum of foot
- S1
- weak plantar flexion
- weak eversion of foot
- depresses ankle jerk
- sensory loss along lateral border of foot
Investigation
Differential Diagnosis
- inflammatory conditions (severe with raised ESR)
- ankylosing spondylitis
- tuberculosis
- vertebral tumours (constant pain, bone destruction, pathological fracture)
- nerve tumours (continuous pain)
Treatment
- soothing
- heat
- analgesics
- excercises
- Rest
- in bed
- hips and knees slightly flexed
- 10kg traction on pelvis
- anti-inflammatory
- Reduction
- epidural injection of corticosteroids + local anaestethic
- Removal
- indications
- cauda equina compression syndrome
- persistent pain, severely limited straight leg raise after 2 weeks
conservative treatment
- neurological deterioration
- frequently recurring attacks
- posterior approach
- dural sac retracted
- material removed
- Rehabilitaion
- isometric exercises
- light work after 1 month
- heavy work after 3 months
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