L/S Disc Herniation

Question 1

What is a herniated disc?

Answer 1

Prolapse of the annular wall and displacement of the nucleus pulposus (often posterolateral). The result is instability.

Question 2

What is the MOI for a herniated disc?

Answer 2

Gradual onset or traumatic flexion/rotation incident.

Question 3

What are the stages of a herniated disc?

Answer 3

i) protrusion: NP bulge
ii) prolapse: BP between annular layers
iii) extrusion: NP burst through annular wall encroaching on spinal foramen
iv) sequestration: fragments of NP in spinal canal

Question 4

What subjective findings might accompany a herniated disc?

Answer 4

i) flexed rotated posture or side flexed away (relieves pressure)
ii) pain on coughing
iii) better with walking, worse with flexed positions
iv) possible neuro signs if compressing neural structures

Question 5

What precautions accompany a herniated disc?

Answer 5

i) no prolonged/repeated flexion or extension

ii) no prolonged sitting

Question 6

What are 5 key objective tests to help determine the presence of a herniated disc and what are the expected findings?

Answer 6

i) neurodynamics: +ve SLR and crossed SLR
ii) neuroconduction: +ve for LMN symptoms
iii) MMTs: weak core muscles and hip stabilizers
iv) Palpation: TOP
v) Repeat flexion (x10): peripheralizes and exacerbates symptoms

Question 7

What are two differential diagnoses for disc herniation and how would you rule them out?

Answer 7

i) Piriformis syndrome: hip ER at rest (piriformis sign), FAIR test +ve, normal neuroconduction, +ve Pace sign
ii) Facet syndrome: (also pain w/ coughing & sitting) extension intolerant, +ve Kemp’s (local), +ve Spring test

Question 8

Foundational exercises for herniated disc?

Answer 8

McGill’s “big three”

i) Curl Up
ii) Side Plank
iii) Bird Dog
- traction, McKenzie extensions