Case 18 Lumbar Disc Herniation


Case 18
Lumbar Disc Herniation
Introduction ownself
Exposure – whole body
Hand scrubbing
Look- Standing Patient

Comment on Lumbar Corset
Attitude of the body  - Listing towards one side , trunk arm distance increased on one side
Look
Alignment       -           Front        Both shoulders and Pelvis are leveled,
                                                     No wasting of Quadriceps muscles
                                                      Patella facing forward and at equal height
Leg, foot and toes look normal with normal        
overlying skin
                                    Side           Elbows straight overlying greater trochanter
                                                       Transverse Loin Creases
     Knee Straight
      Foot Arches maintained 
                                    Back               
Lumbar spine scoliosis
Lumbar spine flattened
 Normal overlying skin on back with no dimpling , tuft of hair
  and swelling
  Calf symmetrical with normal overlying skin
  Heel has – Normal varus
 Feel
Temperature – Normal
Superficial Palpation – Paraspinal Muscle spasm +
Bony Palpation – non tender
Tenderness at 5th Lumbar Spine
Movement –                            Flexion and lateral bending decreased  

Gait                                         Normal / Foot Drop Gait , Disturbance +
Tip toe , heel walking ,

Squating                                  heel at the same level

Standing –      Special tests -Trendelenburg test

Lie down Patient
SLR – decrease to < 60 degrees
Lasegue’s test
Cross Over
Thomas’s Sign (sciatica on extending flexed knee with a flexed hip )
Femoral Nerve Stretch test
FABER Test
FADIR – To rule out Pyriformis Syndrome
                                     
Movement                               Hip / Knee / Ankle / Toes                   
LLD
                                   
Neurovascular Assessment

Sensory Examination             L 2 – S 5  
Motor Examination  -               Global muscle weakness
Power of the Muscles –                      
                                    Supine             Quadriceps ,
TA / EHL /EDC / TP / Peronei
                                                Lateral             Abductor /Adductor
Prone               Gastrosoleus / FHL/FDC /Hamstring/Gluteal Maixums /Medius/Minimus


Reflexes

Vascular Examination – DPA / PTA on supine position



Investigations –
Plain X-ray
MRI





Treatment
Non Operative
            Rest
            Flexion Exercise
            Analgesics
            Nerve Root Blocks
Operative
            Dissectomy – Open  / Microscopic







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