Symptoms will follow a dermatomal distribution
Cervical herniated disk
Patient will present as → a 57-year old male with right arm pain of 4 weeks duration. He reports the pain began following a tennis match and has not improved with time. He describes the pain as an aching sensation that affects his lateral forearm that improves when he abducts the shoulder. He also describes a sensation of numbness in this right thumb. The reflex exam shows he has 1+ right biceps reflexes and 2+ right triceps reflexes which are both symmetric with the left side. A sensory exam shows paresthesias in the distribution of the right thumb. Motor exam shows no evidence of radial deviation with active wrist extension. Motor exam on the right shows 5/5 deltoid, 5/5 elbow flexion with the palms facing upward, 4/5 wrist extension, and 5/5 elbow extension, and 5/5 wrist flexion.
The clinical presentation is most consistent with C6 radiculopathy. This would be caused by a paracentral cervical disc herniation at C5/6.
|Usually posterolateral at C5-C6, C6-C7
|Disk space||Nerve root||Muscle||Reflex||Sensory|
|C4-5||C5||Deltoid, supraspinatus, infraspinatus||Biceps||Lateral arm|
|C5-C6||C6||Biceps, wrist extensors||Biceps, brachioradialis||Radial forearm, thumb, index finger|
|C6-7||C7||Triceps, wrist flexors, finger extensors||Triceps||Middle finger|
|C7-T11||C8||Finger flexors||None||Fourth and fifth fingers|
|T1-2||T1||Finger abductors||None||Ulnar forearm|
Lumbar herniated disk
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Patient will present as → a 35-year-old male presents with a three-month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the dorsal aspect of his foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MRI images are obtained.
The clinical presentation is consistent with a lumbar disc herniation with symptoms of a combined L5 and S1 radiculopathy
|Diagnosis of Lumbar Disk Herniation
Pain in a dermatomal pattern - increases with coughing, straining, bending, and sitting
Look for "red-flag" symptoms:
Lumbar radiculopathy most commonly involves either the L5 or S1 root.
Which of the following statements about lumbar disc disease is true?
Question 1 Explanation:
Lumbar disc disease usually results from posterior herniation of the nucleus pulposus that impinges on the spinal cord. The most common site is the L5-S1 interspace, which affects the first sacral nerve root. Patients typically recall a precipitating event such as lifting a heavy object. Symptoms include severe back pain that radiates to the legs and is aggravated by coughing, sneezing, or forward flexion of the trunk. The condition is the most common cause of sciatica. Examination may show decreased sensation in a dermatome pattern, weakness, decreased reflexes, and a positive straight leg-raising test. In severe cases, patients may experience bowel or bladder incontinence. Radiographs and laboratory tests are generally unnecessary, except in the few patients in whom a serious cause is suspected on the basis of a comprehensive history and physical examination. Surgical evaluation is indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment. Bed rest should not be recommended for patients with nonspecific acute low back pain. Moderate quality evidence suggests that bed rest is less effective at reducing pain and improving function at 3 to 12 weeks than advice to stay active. Prolonged bed rest can also cause adverse effects such as joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and venous thromboembolism (VTE). The treatment plan should be reassessed in patients who do not return to normal activity within 4 to 6 weeks. Most mild cases can be treated with the limitation of aggravating activity, anti-inflammatory agents, and muscle relaxants.
A 26-year-old male was lifting a heavy object two weeks ago when he felt a sudden onset of low back pain. He describes pain in the low mid back at the belt line aggravated with movement. Radicular symptoms are noted in the left buttock down the leg to the dorsal aspect of the foot. He denies any urine or bowel complaints His examination demonstrates an inability to stand on his toes and a positive straight leg raise. Which of the following is most appropriate diagnostic study in this patient?
Question 2 Explanation:
MRI is the diagnostic study of choice in a patient with suspected disc herniation.
What spinal nerve root is most likely affected in a patient with weak wrist extension, thumb and index finger paresthesias and diminished triceps reflex?
Question 3 Explanation:
In contrast, cervical 5 would be associated with deltoid and biceps weakness and diminished biceps reflex while cervical 7 would result in triceps weakness and paresthesias in the middle finger and diminished brachioradialis reflex. Review Topic: Herniated nucleus pulposus
A 65-year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected?
Question 4 Explanation:
The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles. Review Topic: Herniated nucleus pulposus
There are 4 questions to complete.
A herniated disk also referred to as a herniated nucleus pulposus (HNP), is a structural deterioration of the intervertebral discs that provide shock absorption for the spine. Also known as “slipped disc,” damage to the disc enables the nucleus pulposus to seep through the torn or stretched annulus and bulge outward between the vertebrae. HNP frequently occurs between L5-S1 or the fourth and fifth lumbar vertebrae. Causes of HNP include natural degeneration, spine trauma, and spinal stenosis. Assessment findings include radiating pain, lower extremity weakness, and bowel/bladder incontinence. Diagnostic studies to determine structural defects and locate damaged sites include x-rays, myelogram, MRI, and CT scan. Interventions for HNP include wearing a brace to support the spine. Medications include NSAIDs, opioids, analgesics, epidural corticosteroids, muscle relaxants, and antidepressants. Invasive procedures indicated for patients with HNP include intradiscal electrothermal plasty (IDET), interspinous process decompression, laminectomy, discectomy, spinal fusion, and artificial disc replacement.
|Herniated Nucleus Pulposus||Play Video + Quiz|
The skin’s surface is divided into specific areas called dermatomes, which are mainly supplied by a single spinal. There are 8 cervical nerves (C1 being an exception with no dermatome), 12 thoracic nerves, 5 lumbar nerves, and 5 sacral nerves. Each of these nerves relays sensation (and pain) from a particular region of the skin to the brain.
|Dermatomes – Cervical||Play Video + Quiz|
|Dermatomes – Thoracic||Play Video + Quiz|
|Dermatomes – Lumbosacral||Play Video + Quiz|