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)
§ 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