Lumbar Disc Disease

Ovid: 5-Minute Sports Medicine Consult, The

Lumbar Disc Disease
Matthew D. Shores
  • In regard to terminology, lumbar disc disease may represent a broad spectrum of pathology, including disc herniations, disc space narrowing, disc desiccation, and sclerosis of the end plates, as well as many lumbar spine abnormalities with various etiologies:
    • Most commonly, the term refers to lumbar disc herniation, and this topic most specifically addresses lumbar disc herniation.
  • Lumbar disc herniations are the most common cause of sciatica, although not the only cause.
  • Approximate lifetime incidence is 5% in males and 2.5% in females.
  • Peak incidence is between the 4th and 6th decades of life (30s to 50s).
Risk Factors
  • Lifestyle risks include sedentary occupations, physical inactivity, and smoking.
  • Increased tendency in families with acquired spinal disorders, such as ankylosing spondylitis and degenerative arthritis.
  • In addition, more common in patients with increased height and weight.
  • Compromise in the integrity of the annulus fibrosus may allow herniation of the nucleus pulposus.
  • Herniation of the nucleus pulposus of the disc may compress and irritate the adjacent nerve root.
  • Most common site of herniation is L5–S1, affecting the S1 nerve root. 2nd most common site of herniation is L4–L5, affecting the L5 nerve root.
  • Often presents with history of multiple episodes of back pain that vary in severity and duration:
    • This accumulated recurrent back pain can lead to disc herniation.
    • May present following an acute lifting or twisting injury
    • Often worsened by coughing, sneezing, and Valsalva
  • Presents with sciatic pain, that is, pain originating in the low back and radiating from the buttock down the posterior or lateral thigh to the ankle or foot:
    • Patients may have a difficult time finding a position of comfort.
  • Sciatica has a high sensitivity for lumbar disc herniation but low specificity:
    • More specific for disc herniation if pain is greater in the leg than in the back or pain that is worse with the Valsalva maneuver.
  • Can present with back pain that does not radiate, but patient may note motor or sensory deficits.
  • Red flag symptoms that may indicate an alternative diagnosis, including cauda equina syndrome, infection, or neoplasm:
    • Fecal incontinence
    • Loss of motor function
    • Perianal numbness
    • Radicular symptoms lasting >6 wks
    • Saddle anesthesia
    • Urinary retention
    • Unexplained fever
    • Weight loss
Physical Exam
  • A full physical exam of the back, pelvis, and lower extremities should be done, including a detailed neurological exam.
  • Provocative tests should include a straight leg raise test, the most sensitive test for lumbar disc herniation (1):
    • Straight leg raise can be done seated or supine, although for lumbar disc herniation, supine test has higher sensitivity (1).
    • Crossed straight leg raise is highly specific for lumbar nerve root entrapment, including that caused by lumbar disk herniation.
  • Other findings may include:
    • Sensory loss:
      • Medial foot, including plantar aspect of 1st toe sensory loss (L4 involvement)
      • Dorsum of the foot sensory loss (L5 involvement)
      • Lateral heel sensory loss (S1 involvement)
    • Tendon reflex changes:
      • Diminished or lost patellar tendon reflex (L4 involvement)
      • Please note: There is no L5 tendon reflex
      • Diminished or lost Achilles reflex (S1 involvement)
    • Motor finding (often late findings):
      • Weak tibialis anterior and quadriceps (L4 involvement)
      • Weak foot inversion, eversion, dorsiflexion, and 1st toe extension (L5 involvement)
      • Weak hamstrings or gastrocnemius (S1 involvement)
  • Please note Waddell's signs to assess malingering:
    • Tenderness:
      • Superficial tenderness with light palpation or tenderness on deep palpation but nonanatomic over a large area
    • Simulated tests:
      • Axial loading causes low back pain, or rotation of the hips and shoulders together causes low back pain
    • Distraction:
      • Formal straight leg raise is positive, but when distracted, straight leg raise does not produce pain.
    • Regional sensory or motor changes:
      • Glove and stocking sensation loss or nonanatomic muscular weakness (various muscles innervated by different nerve roots)
    • Overreaction:
      • Exaggerated response or emotions
Diagnostic Tests & Interpretation
  • MRI is the preferred imaging modality; however, in the absence of red flag symptoms, MRI should be delayed for a 6-wk trial of conservative treatment. If symptoms persist beyond 6 wks, MRI may then be considered (1)[A]:
    • Please note, it has been demonstrated that in asymptomatic patients under the age of 60 with no history of back complaints, ∼50% of patients had bulging discs and nearly 25% had herniated discs on MRI (2,3).
  • Emergent imaging may be considered for red flag symptoms such as urinary retention, fecal incontinence, saddle anesthesia, progressive neurologic changes, and intractable pain.
  • Plain radiographs may be beneficial to rule out bony abnormalities (such as metastic disease or fractures); in addition, they may demonstrate age-related degenerative changes.
Differential Diagnosis
  • Cauda equina syndrome
  • Hip arthritis
  • Knee arthritis
  • Meralgia paresthetica
  • Piriformis syndrome
  • Sacroiliitis
  • Spinal neoplasms
  • Spinal stenosis
  • Trochanteric bursitis
  • Vascular insufficiency
  • Vertebral fracture or infection


  • 722.10 Displacement of lumbar intervertebral disc without myelopathy
  • 722.52 Degeneration of lumbar or lumbosacral intervertebral disc
  • 722.73 Intervertebral disc disorder with myelopathy, lumbar region

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