Daily Bolus of LR: Lumbar Disc Herniation

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March 31, 2011 by dailybolusoflr

Lumbar Disc Herniation

·         Most patients with lumbar disc herniations are between 30-50 years old

·         Radicular symptoms occur when the nucleus pulposus of the disc protrudes through the annulus fibrosis and causes local nerve root inflammation

·         Sciatica, or pain in a radicular disctribution, is present in up to 95% of patients with lumbar disc herniation

·         Patients with atraumatic mechanisms (heavy lifting is not considered traumatic) do not need to be imaged in the immediate period unless there are red flags present.

o   Red flags include:

§  Extremes of age (under 18 and over 50)

§  Fever

§  Immunocompromise

§  History of cancer or systemic symptoms suggestive of cancer

§  Duration of symptoms greater than 6 weeks

·         Bed rest is no longer thought to be helpful in patients with back pain and patients should be encouraged to carry out activities of daily living.

·         Pain control should be adequate and can include anti-inflammatory medications and narcotic pain medications as needed. 

Nerve Root- Possible Findings:

L2            Weakness in hip flexor

L3            Weakness in quadriceps; patellar reflex decreased; pain and/or loss of sensation to anterior thigh

L4            Weakness in quadriceps, patellar reflex decreased (less than L3); pain and/or loss of sensation to anterior thigh; loss of sensation to medial foot

L5            Weakness of anterior tibialis/great toe/hip abductors; loss of sensation to dorsum of foot and great toe; pain down side of leg

S1           Weakness of gastrocnemius, plantar flexion; loss of sensation to lateral foot/little toe; Achilles reflex decreased; pain down back of leg into bottom or side of foot



Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions


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