an L4/L5 herniation would affect the L5

Acute sciatica probably due to disc extrusion. Both the sensory distribution, the paresis for plantar flexion (tiptoe) and the absence of the Achilles reflex are typical of S1 root involvement, which is typically affected with L5/S1 disc herniation (posterolateral). An L1/L2 (posterolateral) herniation would affect the L2 root, an L4/L5 herniation would affect the L5 and cauda equina would involve more symptomatology than simple S1 involvement.

A 36-year-old man with no PA of interest comes to the emergency department with sudden onset of severe pain in the posterior aspect of the right lower limb extending to the foot. On examination he presented: Positive right Lasège at 10º, decreased strength in plantar flexion of the right foot, hypoesthesia in the external border of the right foot and absence of right Achilles reflex. The simple X-ray of the lumbar spine does not show significant alterations. Which of the following is the most probable diagnosis?

Intradural lumbar disc herniation associated with degenerative spine disease and rheumatoid arthritis.

A case report. To demonstrate a case of intradural lumbar disc herniation including imaging studies, intraoperative imaging, and an intraoperative video. The first case of lumbar intradural disc herniation was reported as early as 1942; since then more than 150 cases have been reported, mostly in the lumbar spine. Gadolinium-enhanced magnetic resonance image (MRI) is considered the "gold standard" for diagnosing this entity, although it is rarely performed routinely in lumbar disc disease and diagnosis is often made intraoperatively. A 70-year-old man presented to the emergency department as a referral complaining of lower back pain, loss of sensation in the right thigh, and difficulty walking. On examination, he showed uneven gait, right-sided foot drop (1/5), hypesthesias in the right inguinal area and ventral thigh, and a positive straight leg raise test on the right. Anal sphincter tone was within normal limits. A magnetic resonance image of the lumbar spine showed a large mediolateral herniated disc at L3-L4, with caudal displacement and unclear signal changes intradurally. Intraoperatively, the herniated disc was found upon opening the dural sac. Intradural disc herniations are a rare entity. The opening and inspection of the dural sack should be considered when the correct spinal level can be confirmed and insufficient herniated disc material can be visualized extradurally.

Report of an Isolated L5 Radiculopathy Caused by an L2-3 Disc Herniation and Review of the Literature.

Intervertebral disc herniation is a common cause of radiculopathy. Disc herniations occurring in the lumbar spine typically affect the nerve root exiting under the pedicle of the vertebral body, one level caudal. However, in rare cases, a disc herniation can cause remote isolated radicular symptoms. The authors present the case of a 70-year-old male who presented with an acute, new-onset, left-sided foot drop, low back pain, and a classic L5 monoradiculopathy. Imaging revealed a large, left-sided paracentral extruded L2-3 disc and the absence of any pathology at the L4/5 level. Although the patient's clinical presentation and imaging did not classically correlate, it was felt that the L2-L3 disc was the etiology of the patient's L5 radiculopathy and a left L2-3 microsurgical discectomy was performed. At the six-week follow-up, his foot drop was near normal, sensation was intact with minimal paresthesias, and he remained pain-free. At the one-year follow-up, he experienced full resolution of his foot drop and remained symptom-free. Although rare, disc herniations may cause isolated, remote, painful mononeuropathies not related to the direct level of nerve root compression and should be considered along with other etiologies of peripheral neuropathies.

Intraradicular lumbar disc herniation: case report and review of the literature.

Intradural or intraradicular herniation of a lumbar disc is a rare complication of disc disease. The mechanism of the tearing of the dura mater by a herniated disc is not known with certainty. Only six cases of intraradicular disc herniation have been reported. By reporting the seventh case of this rare neurosurgical entity, we emphasize its importance and review the literature on intraradicular disc herniation. A 41-year-old man was admitted with a 3-year history of low back pain and sciatica. A neurological examination revealed motor weakness during plantar flexion, positive Lasègue's sign, sensory deficit on the S1 dermatoma, and loss of Achilles reflex. Magnetic resonance imaging revealed disc protrusion at the L5-S1 level. Therefore, we decided to operate on the patient having made a diagnosis of lumbar disc disease. The patient underwent a standard hemilaminotomy and foraminotomy for a removal of the L5-S1 disc. There was no disc protrusion or extruded fragment. The left S1 nerve root was observed to be swollen and immobile. A longitudinal incision was made on the radicular sheet of the S1 root, and a free disc fragment, approximately 2 x 1 x 1 cm, was extirpated in one piece. The patient was immediately relieved of pain and was discharged on the 7th day after the operation with normal muscle strength. It seems probable that in some patients with "failed back syndrome," intraradicular or intradural disc herniation is the cause of failure.

Acute Bilateral Isolated Foot Drop: Changing the Paradigm in Management of Degenerative Spine Surgery with Percutaneous Endoscopy.

Acute bilateral isolated foot drop due to lumbar disk prolapse with canal stenosis is rare with only 3 cases reported in literature. Our patient was managed using the percutaneous full endoscopic technique. This is mainly to highlight the ease of access and patient outcome with preoperative and postoperative images to support our minimally invasive treatment for this rare condition. A 46-year-old male presented with sudden-onset severe back pain with bilateral foot drop. Clinical examination showed a bilateral L5 radiculopathy with normal perianal sensation. Investigations excluded other causes of bilateral foot drop. A magnetic resonance imaging scan showed disk herniation at the right L4-L5 (inferior migrated) and L5-S1 level (paracentral and extraforaminal) with spinal canal stenosis at the L2-L3 and L5-S1 levels due to ligamentum flavum hypertrophy. The patient underwent percutaneous endoscopic stenosis lumbar decompression at the L2-L3 and L5-S1 level. At the right L4-L5, L5-S1 level, transforaminal endoscopic diskectomy was done using the conventional percutaneous approach. The inferior migrated disk of the L4-L5 level was removed using a left L5-S1 contralateral approach. The patient recovered with favorable outcome and added benefits of minimally invasive surgery. Lumbar disk prolapse with canal stenosis should be considered in patients presenting with bilateral isolated foot drop. To our best knowledge, this is the first report of percutaneous endoscopic treatment to address multiple-lumbar-level pathology for this rare condition of acute bilateral isolated foot drop.

Disc Herniation -- History and Physical -- Physical Examination

L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf, and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex. S1 Nerve - back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.

Intraradicular disc herniations in the lumbar spine and a new classification of intradural disc herniations.

A case report of intraradicular disc herniation. Intraradicular disc herniation is a special type of intradural disc herniations. In this report, we present the tenth case of intraradicular lumbar disc herniation and suggest a new classification for intradural disc herniations. A 32-year-old male was admitted to hospital having experienced pain in the lower back and right leg for 1 month prior to admission. Neurological examination revealed weakness of the extensor hallucis longus, positive Laségue's sign, decreased ankle reflex in his right lower extremity, and bilateral paravertebral muscle spasm. Magnetic resonance imaging (MRI) revealed a disc herniation with a posterolateral extruded fragment on the right at the level of the L5-S1 space. He underwent L5 laminectomy. During the operation, the right S1 root was found to be swollen and immobile. A longitudinal incision was made in the dura of the right S1 root and an intradural free disc fragment was removed, and the S1 root was relieved. The patient was free of pain postoperatively. We suggest a new classification for intradural disc herniations with this unusual case presentation and review the literature for pathogenesis, clinical picture, diagnosis and treatment.

Neurology_Adams

Table 10-1. Generally, disc herniation compresses the root of the level just below the herniation (see below). Hypotonia may be evident on inspection and palpation of the buttock and calf. In only a few patients is a foot drop (L5 root) or weakness of plantar flexion (S1 root) the main feature of disc protrusion, but it is notable that some patients have little pain with disc rupture. The reflex changes noted below have little relationship to the severity of the pain or sensory loss. Furthermore, compression of the fourth, or sometimes fifth, lumbar root may occur without any change in the tendon reflexes. Bilaterality of symptoms and signs is rare, as is sphincteric paralysis, but they occur with large central protrusions that compress the cauda equina. The cerebrospinal fluid (CSF) protein is then slightly elevated, usually in the range of 55 to 85 mg/dL, sometimes higher.

Motor evoked potential study suggesting L5 radiculopathy caused by l1-2 disc herniation: case report.

A 38-year-old male was referred because of pain in the left 5th lumbar (L5) root territory. Physical examination found moderate motor weakness in the left extensor hallucis longus (EHL) and the left tibialis anterior muscles. Magnetic resonance imaging found no stenotic lesion between L4-L5, but disc herniation was observed on the left between L1-L2. An L5 nerve root block provided temporary relief of the pain but the left foot weakness was exacerbated. Therefore, surgery was performed. Partial laminectomy and left herniotomy were performed at L1-L2, L2-L3, and L3-L4 with motor evoked potential (MEP) monitoring. The MEP amplitude of the left EHL muscle increased immediately after L1-L2 herniotomy. The MEP amplitude of the right EHL muscle also increased after both laminectomy and herniotomy. The postoperative course was uneventful. The left leg pain and motor weakness disappeared. The patient has been doing fine without recurrence for 12 months. Since the MEP of both left and right EHL muscles improved after the L1-2 herniotomy, circulatory insufficiency might have caused the L5 symptoms. Monitoring of the MEP during the surgery was useful for confirming the responsible lesion and also for predicting the postoperative course.

Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation.

Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation. To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5-S1 disc herniation. A total of 32 patients (average age: 49.4 years, range: 23-78) with L5-S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical "The Medical Research Council of the United Kingdom" method. The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz-Ilbay plantar flexion test yielded the correct classification for all cases. We suggest that the proposed method "Yilmaz-Ilbay plantar flexion test" can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5-S1 herniation.

Lumbar Disc Herniation -- History and Physical

L5 nerve root exits at the L5-S1 foramina. When compressed by a herniated disc, it causes back pain that radiates into the buttock, lateral thigh, lateral calf, the dorsum of the foot, and the great toe. Sensory loss is present on the web space between the big toe and second toe, the dorsum of the foot, and lateral calf. There is a weakness in hip abduction, knee flexion, foot dorsiflexion, big toe dorsiflexion, foot inversion, and eversion. Patients present with decreased semitendinosus/semimembranosus reflex. Weakness in foot dorsiflexion makes it challenging to walk on the heels. Chronic L5 radiculopathy may cause atrophy of the extensor digitorum brevis and the tibialis anterior of the anterior leg.

S1 nerve root exits at the S1-S2 foramina, assessed with the Achilles reflex. When compressed with a herniated disc, it presents with sacral or buttock pain that radiates into the posterolateral thigh, the calf, plantar or lateral foot or the perineum. Sensory loss is present on the calf, lateral, or plantar aspect of the foot. There is weakness on foot plantar flexion, hip extension, and flexion of the knee. Weakness in foot plantar flexion causes an inability to tiptoe walk. It could also cause urinary and fecal incontinence and sexual dysfunction. [5] [8] [9]

Neurology_Adams

Rupture of one of the lower lumbar intervertebral discs is the most common cause of sciatica, although it does, of course, not directly involve the sciatic nerve. The associated motor and sensory findings allow localization of the root compression (L4-L5 disc compressing L5 root: pain in posterolateral thigh and leg with numbness over the inner foot and weakness of dorsiflexion of the foot and toes; L5-S1 disc compressing S1 root: pain in posterior thigh and leg, numbness of lateral foot, weakness of foot plantar flexion and loss of ankle jerk), as discussed in Chap. 10.

InternalMed_Harrison

The straight leg–raising (SLR) maneuver is a simple bedside test for nerve root disease. With the patient supine, passive flexion of the extended leg at the hip stretches the L5 and S1 nerve roots and 113 CHAPTER 22 Back and Neck Pain 4th Lumbar vertebral body 5th Lumbar vertebral body 4th Lumbar pedicle L4 root Protruded L4-L5 disk L5 Root S1 Root S2 Root Protruded L5-S1 disk FIguRE 22-3 Compression of L5 and S1 roots by herniated disks. (From AH Ropper, MA Samuels: Adams and Victor’s Principles of Neurology, 9th ed. New York, McGraw-Hill, 2009; with permission.) the sciatic nerve. Passive dorsiflexion of the foot during the maneuver adds to the stretch. In healthy individuals, flexion to at least 80° is normally possible without causing pain, although a tight, stretching sensation in the hamstring muscles is common. The SLR test is positive if the maneuver reproduces the patient’s usual back or limb pain. Eliciting the SLR sign in both the supine and sitting positions can help

Foot Drop in Obstetrics -- History and Physical

If positive, the Lasegue straight-leg raising test indicates a proximal lesion such as a herniated lumbar disc. [19] For the foot drop, the appropriate disc would be the L4/L5 disc. If there is a herniated L4/L5 lumbar disc, the pain pattern will follow the L5 dermatome (area of skin innervated by a single dorsal root). If the test is positive, examine the patient for paralumbar muscle spasm, which will probably accompany the herniated lumbar disc. The presence of a herniated lumbar disc can be confirmed by an MRI. [20] MR neurography can be especially helpful in localizing the lesion. [21] The Achilles tendon reflex should be normal (unless the lesion also involves the S1 nerve root). [3] One should then obtain a neurological consultation to determine the precise localization of the patient’s lesion. It is important to reassure the patient that she did nothing wrong and that an obstetrical foot drop should respond well to treatment if she follows the treatment plan.

Foot Drop in Obstetrics -- Evaluation -- Lasegue Straight Leg Raising Test for Radicular Pain Due to a Herniated Lumbar Disc

For disc L5/S1, the S1 dermatome covers the heel and posterior side of the foot and both anterior and posterior sides of the fourth and fifth toes (Foerster). The S1 nerve root is associated with the Achilles tendon reflex. [3] Damage to this root will cause loss of the Achilles tendon reflex.

Symptoms of thoracolumbar junction disc herniation.

A retrospective clinical review of patients with thoracolumbar junction disc herniation. To evaluate the clinical features of thoracolumbar junction disc herniation and to prepare a chart for the level diagnosis in the neurologic findings and symptoms. Thoracolumbar junction disc herniations show a variety of signs and symptoms because of the complexity of the upper and lower neurons of the spinal cord, cauda equina, and nerve roots. Furthermore, much is still unknown about thoracolumbar junction disc herniations because of their rare frequency. The clinical features of 26 patients who had undergone operations for single disc herniations at T10-T11 through L2-L3 were investigated. Affected levels were as follows: 2 patients with disc herniation at T10-T11 disc, 4 patients at T11-T12, 3 patients at T12-L1, 6 patients at L1-L2, and 11 patients at L2-L3. The level of disc space of interest was confirmed with whole-spine plain roentgenograms. The caudal end of the cord was judged by magnetic resonance imaging and computed tomographic myelogram. Two patients with T10-T11 disc herniation showed moderate lower extremity weakness, increased patellar tendon reflex, and sensory disturbance of the entire lower extremities. Three of four patients with T11-T12 disc herniation experienced lower extremity weakness, and three patients had accentuated patellar tendon reflex. Sensory disturbance was observed in the anterolateral aspect of the thigh in one patient and on the entire leg in three patients. Bowel and bladder dysfunction was noted in three patients. In the T12-L1 disc herniation group (n = 3), muscle weakness and atrophy below the leg were advanced, and bowel and bladder dysfunction were also noted. Two of these three patients had bilateral drop foot, and one patient had unilateral drop foot; sensory disturbance was noted in the sole or foot and around the circumference of the anus, and the patellar tendon reflex and Achilles tendon reflex were absent. All six patients with L1-L2 disc herniation showed severe thigh pain and sensory disturbance at the anterior aspect or lateral aspect of the thigh. On the other hand, there were no clear signs of lower extremity weakness, muscle atrophy, deep tendon reflex, or bowel and bladder dysfunction in these patients. In the L2-L3 disc herniation group (n = 11), all patients had severe thigh pain and sensory disturbance of the anterior aspect or the lateral aspect of the thigh. Weakness in the quadriceps was noted in five patients and weakness in the tibialis anterior in two patients. Decreased or absence of patellar tendon reflex was observed in nine patients. Five patients had positive straight leg raising test results, and eight patients showed positive femoral nerve stretch test results. Among thoracolumbar junction disc herniations, T10-T11 and T11-T12 disc herniations were considered upper neuron disorders, T12-L1 disc herniations were considered lower neuron disorders, L1-L2 disc herniations were considered mild disorders of the cauda equina and radiculopathy, and L2-L3 disc herniations were considered radiculopathy. These findings had relatively distinct differences among herniated disc levels.

A straight leg raise test is a neurological maneuver performed while examining a patient presenting with lower back pain. It is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner slowly elevates the leg progressively at a slow pace. The test is positive when it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 45 degrees with radiation below the knee (Lasegue sign). It is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner is raising the leg (Bragaad's sign) to increase the sensitivity of the test.

[L1-2 lumbar disc herniation: a case report].

A 49-year-old female presented a two-year history of pain in the right thigh and lower back. Neurological examination on admission demonstrated weakness of the right iliopsoas and quadriceps, hypesthesia on the right L1-2 dermatome. Radiological examination including myelography, CT myelography and discography disclosed an L1-2 herniated disc. Sagittal MRI also revealed an L1-2, an L4-5 and L5-S1 protruded disc. A posterior microdiscectomy (Love's method) was performed for the L1-2 disc. A controlateral protruded disc which compressed the L-2 nerve root was identified and partially removed. The postoperative myelography showed residual disc. The patient was free from pain and regained normal sensorimotor function. Love's posterior microdiscectomy has a disadvantage in that the operative field is limited. Careful surgical procedure was needed to avoid injury to nerve roots and the cauda equina in a tight L1-2 lumbar canal.

Sciatica -- History and Physical

Another maneuver is the crossed straight leg test, similar to the straight leg raise test but is conducted on the asymptomatic leg instead. The crossed straight leg test is considered positive if the patient reports pain in the symptomatic leg while the asymptomatic leg is at a 40° angle, representing a central disc herniation with severe nerve root irritation. L3 radiculopathy includes weakness of hip adduction, knee extension, and sensory pain in the anteromedial dermatome of the thigh. Ankle dorsiflexion weakness and absent patellar reflex are present in L4 radiculopathy. Hip abduction and big toe extension weakness show L5 radiculopathy. S1 nerve root compression presents as absent ankle reflexes.

First_Aid_Step2

Associated with sciatica, paresthesias, muscle weakness, atrophy, contractions, or spasms. T AB LE 2.9-2. Motor and Sensory Deficits in Back Pain L4 L5 S1 Foot dorsifexion (tibialis anterior) Patellar Medial aspect of the lower leg. Big toe dorsifexion (extensor hallucis longus), foot eversion (peroneus muscles) None Dorsum of the foot and lateral aspect of the lower leg. Plantar fexion (gastrocnemius/soleus), hip extension (gluteus maximus). Achilles Plantar and lateral aspects of the foot. A passive straight leg raise ↑pain (highly sensitive but not specific). A crossed straight leg raise ↑ pain (highly specific but not sensitive). Large midline herniations can cause cauda equina syndrome. Obtain an ESR and a plain radiograph if other causes of back pain are suspected (e.g., infection, trauma, compression fracture). Order a stat MRI for cauda equina syndrome or for a severe or rapidly progressing neurologic deficit.

Nerve root

Lower limb radiculopathies The cause is a herniated intervertebral disc, often on a single nerve root. The first sign of the nerve root sickness is usually lumbago, which usually occurs with periods of remission. The time to develop a full radicular syndrome may take several months or several years. Pain generally increases gradually, but it can also be sudden. Cold causes muscle contraction, which leads to increased previously hidden symptoms. Symptoms Scoliosis Paraspinal muscle contracture The reduction of lumbar lordosis Tingling or numbness Increased sensitivity Other inflammatory diseases L4 radiculopathy Pain located on the front of the thigh and shin further radiates towards the inner ankle, sometimes the medial toe Occasionally, failure of the quadriceps muscle and reflex weakness L5 radiculopathy Pain radiates to the side of the thigh and lower leg towards the back of the foot and toes 1–3 All reflexes are preserved

Neurology_Adams

Fig. 10-3) and between the fourth and fifth lumbar vertebrae (compressing the L5 root). Lesions of the fifth lumbar root (L5) produce pain in the region of the hip and posterolateral thigh (i.e., sciatica) and, in more than half such cases, lateral calf (to the lateral malleolus), and less often, the dorsal surface of the foot and the first or second and third toes. Pain is elicited by the straight-leg raising test or one of its variants, and protective nocifensive reflexes come into play, limiting further elevation of the leg. Paresthesia may be felt in the entire territory or only in its distal parts. The tenderness is in the lateral gluteal region and near the head of the femur. Weakness, if present, involves the extensors of the big toe and foot and the foot invertors (a distinguishing feature of foot drop originating from peroneal nerve damage, which spares inversion because it is a tibial nerve function). The ankle jerk may be diminished (more often it is normal), but the knee

[Treatment of thoracic disc herniation. Case report].

Herniated thoracic intervertebral disc is a rare cause of spinal cord compression. Its frequency varies from 0.15% to 1.7% of all disc herniations, and produces symptoms in 0.5% to 0.8%. Case 1. A 50-year-old woman, with pain and burning sensation in left hemithorax of four months of onset. It was treated as a herpetic syndrome, with no improvement. She was seen after thirteen days of exacerbation of clinical symptoms. The physical examination showed asymmetric paraparesis, lower left pelvic limb 1/5, and right pelvic limb 3/5¸ sensory level T8, with left Babinski positive. A thoracic disc herniation in space T8-T9 was diagnosed. A 55-year-old patient with a history of presenting pain in lumbar area of 5 years onset. She also had radicular pain that radiated to the right pelvic limb, with intensity 10/10 on a Visual Analogue Scale. Her physical examination showed muscle strength 5/5, with normal sensitivity in all dermatomes and tendon reflexes, and a positive right Babinski. Thoracic disc herniation T7-T8 level was diagnosed. Due to anatomical conditions that define this type of hernia, the extracavitary posterolateral approach should be the recommended surgical procedure when the simultaneously performed anterior decompression and fixation with posterior instrumentation are the treatments proposed. Despite the different anatomical structures of this special area, it was possible to obtain satisfactory results for both clinical cases.

Anatomy_Gray

The patient’s symptoms and physical examination findings raised serious concern for compression of multiple lumbar and sacral nerve roots in the spine, affecting both motor and sensory pathways. His reduced power in extending his knees and reduced knee reflexes was suggestive of compression of the L4 nerve roots. His reduced ability to dorsiflex his feet and toes was suggestive of compression of the L5 nerve roots. His reduced ankle reflexes was suggestive of compression of the S1 and S2 nerve roots, and his perineal numbness was suggestive of compression of the S3, S4, and S5 nerve roots. A diagnosis of cauda equina syndrome was made, and the patient was transferred for an urgent MRI scan, which confirmed the presence of a severely herniating L2-3 disc compressing the cauda equina, giving rise to the cauda equina syndrome (Fig. 2.70). The patient underwent surgical decompression of the cauda equina and made a full recovery.

[L5-S1 herniated disk migrated to the anterior part of the right sacral wing with compression of the right lumbosacral roots].

The goal of this study was to report an exceptional case of far lateral and anterior disc herniation at L5-S1 level. A 47 year-old man presented a right L5 radicular pain with motor deficit of tibialis anterior and extensor hallucis longus resisting to medical management. Standard X-rays showed a degenerative process of L5-S1 disc. The CT scan was at first considered as normal. The myelogram was normal. A second study of the CT scan showed an opacity next to the L5 right root in front of the sacral wing. A discography combined with CT scan was then performed showing the migrated herniated disc from L5-S1 to the anterior part of the right sacral wing in contact with L5 root. Surgery was performed by transperitoneal approach and needed a difficult dissection of hypogastric vessels. The herniated disc was found behind the L5 root. A L5-S1 disc excision and arthrodesis with iliac grafts were performed. The result has been very good with relief of the pain and recovery of the palsy within a month. The lecture of a CT scan should include the far extraforaminal zone if there is no compression in the spinal canal. Such an anterior migration of an herniated disc has not been already described as far as we know.

InternalMed_Harrison

Fever, constant pain uninfluenced by position, sphincter abnormali-115 ties, or signs of spinal cord disease suggest an etiology other than lumbar disk disease. Absence of ankle reflexes can be a normal finding in persons older than age 60 years or a sign of bilateral S1 radiculopathy. An absent deep tendon reflex or focal sensory loss may indicate injury to a nerve root, but other sites of injury along the nerve must also be considered. For example, an absent knee reflex may be due to a femoral neuropathy or an L4 nerve root injury. A loss of sensation over the foot and lateral lower calf may result from a peroneal or lateral sciatic neuropathy or an L5 nerve root injury. Focal muscle atrophy may reflect injury to the anterior horn cells of the spinal cord, a nerve root, peripheral nerve, or disuse.

A diagnosis challenge-L4 nerve root compression as the initial presentation of chronic inflammatory demyelinating polyneuropathy.

The authors present the case of a 65-year-old woman who was admitted for paraparesis and paresthesias in the inferior limbs. The neurological examination revealed the difficulty in extension of the right foot and of the right toe, accompanied by paresthesias located in the anterolateral area of the right leg, dorsum and plantar area of the foot, the reduction of the right knee jerk, and of the ankle tendon jerk both sides. The vertebro-spinal MRI showed lumbar canal stenosis with L4 intraforaminal compression on the right, and L2-L3 on the left. CSF examination revealed mild increase in protein concentration. The morphological picture of the sural nerve biopsy was compatible with a chronic inflammatory neuropathy and severe muscular lesions of neurogenic origin were observed on right gastrocnemius muscle biopsy. The diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) was established. Solu-medrol (0.5 g/d)-5 days, then medrol (prednisolone) was done, followed by improving of the symptomatology. For the relapse of the disease intravenous immunoglobulins (IVIG)-0.4 g/kg/d-5 days was the elective treatment. Six months later she presented a new relapse. IVIG were administered with the remission of the sensitive symptoms. A chronic treatment with medrol was recommended. The diagnosis of L4 disc herniation was obvious in the studied case, but the electroneurographic examination brought extra data for the associated diagnosis of CIDP whose onset was asymmetrical and initially paucisymptomatic. Neither the electroneurographic examination nor the CSF examination were total relevant for CIDP, imposing the sural nerve biopsy. The diagnosis of CIDP involves a team-work composed of neurologist, electroneurophysiologist and neuropathologist.

Pediatric lumbar disc herniation: a report of two cases and review of the literature.

Lumbar disc herniation (LDH) is not a common condition in children. Most reports on pediatric LDH concern the outcomes of surgeries performed in children in whom nonsurgical treatment failed while the outcome of nonsurgical treatment of LDH in children was rarely reported. Case 1: a 10-year-old girl presented with back pain and sciatica in her left leg for over 3 months. The physical examination revealed exacerbation of back pain by waist extension or flexion, and a positive Lasegue's sign was revealed in her left leg. Magnetic resonance imaging (MRI) revealed lumbar disc herniation at the L5/S1 level. She was diagnosed with LDH. After receiving nonsurgical treatment of traditional Chinese medicine (TCM) for 30 days, the girl had mild low back pain and sciatica and the symptoms had resolved completely at the 3-month follow-up. There was no recurrence within the following 2 years. MRI performed 30 months later revealed that the herniated disc did not shrink significantly. However, she was totally asymptomatic at the follow-up performed 30 months later. Case 2: a 13-year-old boy presented with sciatica in his left leg for over 3 months. The physical examination revealed that Lasegue's sign was positive in the left leg, the level of muscle strength in the left ankle plantar flexors was grade 4. MRI revealed a lumbar disc herniation at the L5/S1 level. He was diagnosed with LDH. The boy underwent 2 weeks of TCM treatment, and exhibited a favorable outcome: only mild pain was noticed in his left buttocks after walking for more than 15 min. He was asymptomatic at the 3-month follow-up and there was no recurrence within the next 3 years. MRI scan performed at 40 months later showed no significant resorption of the herniated disc. However, he was totally asymptomatic at the follow-up performed 40 months later. For the nonsurgical treatment of pediatric LDH, resorption of herniated discs is not necessary for favorable long-term outcomes, and children with symptomatic LDH may become asymptomatic without resorption.

Posterior epidural sequestrated disc presenting with contralateral radiculopathy: a very rare case.

Posterior epidural sequestrated disc is a fairly uncommon condition. We report a case of an unusual presentation of posterior epidural migration with contralateral symptoms. We emphasize a high index of suspicion for early recognition and treatment to promote a good neurological recovery. A 58-year-old man with a history of severe back pain for 1 week developed sudden right leg weakness while walking. Neurological examination revealed motor and sensory impairments of the right lower extremities (positive right straight leg raising test, right tibialis anterior grade 2/5, right extensor hallucis longus grade 1/5, decreased pinprick sensation of L4-5 dermatome right side) according to the Standards for Neurological Classification of Spinal Cord Injury as Asia Impairment Scale D. Magnetic resonance images showed an acute disc herniation at L4-5 on the left side, cranially migrated and sequestrated to the posterior epidural area, causing severe compression to the cauda equina in the thecal sac. The patient was successfully treated with surgery (transforaminal lumbar interbody fusion) on an urgent basis. We saw significant neurological recovery on the first day after surgery. Motor power recovery was achieved with a minor deficit at 4 weeks. At the follow-up examination at 3 months, the patient had no residual neurological deficits as Asia Impairment Scale E. Posterior epidural sequestrated disc with contralateral radiculopathy is very rare. This case brings a new presentation of posterior epidural sequestrated disc. To our knowledge, this is the first report of a case with an unusual presentation of contralateral radiculopathy.

Lumbosacral Disc Injuries -- History and Physical

L5 at the L5/S1 level, a disc herniation far laterally into the left/right neural foramen would compress the L5 nerve, resulting in weakness of hip abduction muscles, ankle dorsiflexion (anterior tibialis muscle), and/or extension of the great toe (extensor hallucis longus muscle). S1 at the L5/S1 level, a disc herniation centrally into the canal would compress the S1 nerve, resulting in weakness of ankle plantar flexion (gastrocnemius muscle).

Lumbar Degenerative Disk Disease -- History and Physical

The straight leg raise (SLR) test consists of a supine patient having his/her fully extended leg passively stretched from 0 to about 80 degrees. The onset of radiating back pain in either leg supports a diagnosis of a stenotic canal. A herniation compressing the L5 nerve root will present as a weakness of ankle dorsiflexion and an extension of the great toe. This deficit also may diminish the Achilles tendon reflex. L4 radiculopathy may present with weakness in the quadriceps and a decreased patellar tendon reflex. Documentation is paramount, as these initial findings likely will be used as a baseline for all future evaluations.

Spinal Stenosis -- History and Physical

Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathy symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Patients will present with complaints of cramping pain in the leg, calf, and or buttocks. They might report an increase in pain with walking or standing for prolonged periods and relief when sitting or leaning forward while using a shopping cart. [9] Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh.