Diseases, Disorders information

Physical examination, and you all know this, this is in the hand-out, just a quick and dirty review of the different levels of 4-5 disc, will pick off the exiting nerve root as shown here, 4-5 picks off L5, 51 picks off S1 because of the arrangement of the cauda equina and you have reflex motor and sensory changes again here, note with the L5 radiculopathy, there is no reflex change, that usually is seen with a 4-5 disc. The thing you don’t want to miss is the cauda equina syndrome which is really the only true spinal emergency and you won’t miss it because these patient’s won’t let you miss it, and that is a massive midline prolapse resulting in many, many nerve roots involved. Remember when you are doing a sensory examination and the dermatomes you can see here, the thigh, medial calf, L4, lateral and dorsal foot L5, lateral foot S1, is that these dermatomes are approximate and if you map out dermatomes precisely in many patient’s, you are not going to see this clean a distribution, so if it’s not as precise a sensory loss in an L5 as you would predict with an L5 disc and an L5 root, don’t necessarily rule that out as the source of symptoms because these are approximations.
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Nerve root tension signs are something that are frequently assessed as well, now this is of utility is somebody with sciatica or referred neuropathic pain from disc prolapse. The sciatic nerve root test was described by Lasegue’s, this is the so-called straight leg raise. You have to remember when you do this, though, you are only testing the L5 and S1 roots, you re not testing the roots farther upstream. Classically, this has been described as positive only if it reproduces leg pain, but if you think about it, if you flex someone all the way up to 90 degrees and they don’t have leg pain, they have back pain, that should tell you something right there as well, because what have you done, you flexed the pelvis, you reversed lordosis, you raised intradiscal pressure and you still could be dealing with a bad disc, even in someone without sciatica. Interestingly too, as you do a passive straight leg raising maneuver, the nerve roots really only start to move at about 30 degrees and then they only move several millimeters, so someone, unless they have a massive disc herniation, you wouldn’t expect to find referred pain in the lower deflection in your physical examination. If you want to test the femoral nerve root for an L3 or L4 prolapse and femoral nerve entrapment, you have to do a femoral stretch and that is trunk flexion with hip extension and knee flexion.
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