Cervical Disc Herniation
There is no disc between the C1 and C2 vertebrae.
Essence nerve root emerges between C7 and T1.
It is most commonly seen at C6-7, less frequently at C5-6 distance.
It peaks in the 3 and 4th decades. It occurs most frequently in the lateral-dorsolateral direction.
In patients; It can be radiculopathy, myelopathy, or a combination of the two.
There is a painful syndrome called brachialgia.
Pain starting in the neck; descends to the arm, forearm and hand trace. Pain increases with neck movements.
The lordosis of the neck is reduced.
Head and neck movements are limited.
Muscle strength shows weakness compared to the root involved.
Muscle atrophy develops in the same direction.
Cervical disc herniation often compresses the foraminal nerve at the level of herniation.
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Cervical Disc |
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C4-5 |
C5-6 |
C6-7 |
C7-T1 |
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Percentage of cervical discs |
2% |
19% |
69% |
10% |
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stuck root |
C5 |
C6 |
C7 |
C8 |
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impaired reflex |
deltoid and pectoral |
biceps and brachio-radial |
triceps |
finger reflex |
Lumbar Disc Herniation
The vertical column consists of 33 vertebrae. There are 23 discs between the C2 and S1 vertebrae.
Disc herniation; It is the rupture of the annulus fibrosis and the protrusion of the nucleus pulposus.
It is usually seen in middle ages (40-50 years).
Most common in L5-S1 and later in L 4-LS.
The anterior and posterior longitudinal ligaments attach firmly to the disc and provide support.
The anterior, longitudinal ligament is very strong.
The posterior longitudinal ligament is slightly stronger in the middle, weaker laterally.
Therefore, the most common herniation occurs in the posterolateral direction.
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General features of disc herniations |
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Level |
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L3-L4
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L4-L5
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L5-S1
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Frequency % |
5% |
40% |
%40-45
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press |
L4 |
L5 |
S1 |
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reflex loss |
Patella |
medial hamstrings |
Achilles |
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affected muscle |
Quadriceps femoris |
Tibialis anterior |
gastrocnemius |
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Engine power loss |
In knee extension |
Drop foot, decreased 1st toe dorsiflexion |
In plantar flexion |
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Pain spread |
anterior thigh |
leg side face |
back of leg |
symptoms
1. Back and leg pain:
• The first symptom is localized low back pain. It takes 2-3 weeks.
• Pain is exacerbated by staying in any position for too long, coughing, sneezing, defecating and straining.
• Pain is reduced by flexing the knee and hip.
• L5-S1 (N. ischiadicus): Pain from waist to hip and back of thigh.
• L2-L4 (N. femoralis): Pain radiates from the waist to the hip, from there to the inguinal region and anteromedial thigh.
2. Motor, sensory and/or reflex changes and lethargy:
• L3: A rounded area on the kneecap medially
• L4: Below the kneecap, medialdea
• L5: Below the kneecap, laterally, dorsally of the foot
. S1: Underfoot and lateral
• S2: Back of the leg
3. Neurogenic claudication:
• It often starts after the 5th decade.
• Pain, tingling and numbness increase unilaterally or bilaterally, hip, thigh or leg with walking, sometimes loss of strength, relief of symptoms with sitting, squatting or lying down.
4. Bladder symptoms:
• Decreased bladder sensation is the earliest finding.
• "irritative" symptoms including post micturition residue.
• In radiculopathy, enuresis and drip incontinence are described less frequently.
Nervous Tension Findings
Laseque test (Straight leg raise test=SLR):
• Flexion of the thigh in a supine patient, with the affected leg at knee extension.
• The test is positive if there is pain at 35°-70° or paresthesias at the pain site.
• Stretches L5 and S1 nerve roots.
• The occurrence of pain at an angle of more than 70° has no clinical significance.
Contralaseque Test:
• Lifting the painless leg as in the laseque test causes leg pain on the opposite side.
Femoral nerve stretch test (inverted straight leg raise):
• Patient; in the side-lying position, the thigh is extended with the leg flexed
• If pain occurs in the thigh, the test is positive.
• Often positive in L2 -L3 or L4 nerve root compression.
• In these cases, the Laseque test is often negative (as LS and S1 are not involved).
Surgical Treatment Indications
1. cauda equina syndrome (emergency surgery indication)
• It may be due to the pressure of the massive ruptured disc.
• Often a pre-existing condition (spinal stenosis, tethered cord, etc.) overlaps, usually in the midline, very often in the L4-5.
• It may develop on the basis of spinal stenosis and tense cord syndrome.
Possible Findings:
• Sphincter Disorder: Urinary retention (most constant finding), urinary and/or fecal incontinence, anal sphincter tone is decreased in 60%-SO.
• Saddle Anesthesia: It is seen on the hip, posterior-superior thighs and perineal region.
• Significant Motor Weakness: Usually involves more than one nerve root (mostly points below the lesion level).
• Back and/or leg pain
• There may be bilateral loss of the achille or patella reflex.
• Sexual dysfunction: Usually not detected until later.
2. Progressive loss of strength or acute significant loss of strength (indication of emergency surgery)
3. Failure to respond to medical treatment
4. Recurrent disc herniations