Background
- L5S1 most common
- Recurrent torsional stain of outter annulus
- Annulus – Type 1
- Pulposus – Type 2
- Herniation nucleus pulposus
Location
- Cental
- Paracentral (most common)
- Foraminal / far lateral
Morphologies
- Protrusion – bulge through intact anulus
- Extrrusion – though anulus still continuous with disc space
- Sequestered – free fragment
Presentation
- Sclerotomal pain
- Low back, buttock, posteior thigh
- Radicularr
- Worse with valsavla
- Cauda equina
- Exam
- Weakness
- Hyporeflexia
- SLR (sensittive nott specifici)
- Contra SL (specific not sensitive)
- Lesegue – force ankle DF
- Femoral neve stretch (l1-L4 nerve root)
- Trendelenbeg gait (glue medius weakness L5)
Imaging
- MRI – pain >1month, ed flags
- MRI with Gad
- Fibrosus (enhances)
- Recurrent disc (no enahcne)
Manage
- Non op
- 90% no sugerry
- Extension absd PTT
- Selective root steroids
- Long lasting imrpovemtn in 50%
- Best with extruded discs
- Operative
- Failed non op 6 weeks, origressive signiciant weakness
- Return to acgivity 6 weeks
- Positive predictors
- Leg pain dominent
- Positive SLR
- Correlates with MRRI nerve rroot impgingment
- Married
- Prrogressively worsening pior to surgery
- Pro athletes
- Negative predictors
- WSIB
- Wiltse for far lateral
- Multifidus and logistum
- Inteertransver membrance
The Spine Book 