Low-back pain due to disk herniation

The subject of this section is disk herniation without radicular compression. It is essential to know when disk herniation should be suspected in simple low-back pain. The conditions described thus far have been functional disorders. Here, however, we are faced with a defined pathological lesion with a correspondingly serious prognosis. It must be remembered that many instances of disk herniation are completely devoid of clinical relevance, and for this reason the prognosis is favorable even with conservative therapy. At the same time, dysfunctions play an important role here.



Symptoms
If we discount acute attacks, the clinical course as a rule is more severe than in straightforward functional disorders, that is to say attacks last longer and the condition has a greater tendency to relapse.
Coughing and sneezing are generally very painful. The posture that is particularly difficult for patients to manage is bending forward (even slightly), as over a wash basin, because in this position contraction
of the erector spinae is maximal and therefore the pressure on the disk is at its greatest. The ‘painful arc’ described by Cyriax (1977, 1978) also generally manifests itself in this position. Pain when turning over in bed and when getting up is also highly characteristic.


Clinical signs

In acute cases there is a characteristic antalgic (or relieving) posture that is also adopted in response to radicular pain. The most typical antalgic pattern is lumbar kyphosis with the pelvis displaced toward the side of the lesion (and deviation of the trunk to the opposite side; see Figure 1).





Figure 1 • Typical antalgic posture in acute intervertebral
disk herniation.







Anteflexion while standing is generally severely limited and the straight-leg raising test is positive
(except in lesions at L3/L4 where the femoral nerve stretch test is positive). All movement that is
at odds with the antalgic posture is painful. There need not be any movement restriction in the segment affected by disk herniation. When movement restriction is present simultaneously, springing of the lumbar spine continues to elicit pain even after the restriction has been released. Conversely, an (experimental) traction test may bring marked pain relief. In the more chronic stage, anteflexion is limited while standing, but normal when the patient is seated (with knees flexed). Another very typical sign is the painful arc described by Cyriax (1977, 1978) (see Section 4.6.1). Here, too, the straightleg raising test and the femoral nerve stretch test in segment L3/L4 are positive, much more so than when there is only joint restriction. A most valuable diagnostic sign is pain on springing the lumbar spine, irrespective of whether restriction is present or not.



Therapy
Manual traction taking account of antalgic posture may be attempted in the acute stage. In other
words, if the antalgic posture is in kyphosis, then traction is performed with the patient supine over
the practitioner’s knee, but if the antalgic posture is in lordosis, then traction is performed with the
patient lying prone. If traction is well tolerated it may procure immediate relief. Counterstrain to
exaggerate the antalgic posture is also highly effective. This might be termed ‘manipulative first aid.’ If these techniques fail to bring immediate relief, epidural anesthesia and bed rest in the antalgic posture should be considered, as should analgesic medication. However, bed rest should be kept as brief as possible because energetic (‘aggressive’) therapy in the acute stage is the most important step in preventing chronicity. Traction may also be helpful in the chronic stage, provided that the patient finds it agreeable and improvement is detected afterward. In every instance it is important to proceed in a manner that is consistent with the clinical findings, and this approach presupposes a fresh examination at every follow-up visit. In this process, chain reaction patterns should be sought in order to shed light on the pathogenesis. Current knowledge indicates that the commonest causes are to be found in the deep stabilizer system (in conjunction with faulty breathing), the feet, faulty movement patterns, active scars, movement restrictions, and TrPs in the key region as well as the fascia.

No less important are general measures: these include avoiding situations that routinely trigger
recurrences, and protecting the lumbar region against chill after perspiring.


Lewitt Karel. Manipulative Therapy, Musculoskeletal Medicine. 1st edition published in English © 2010, Elsevier Limited. ISBN: 978-0-7020-3056-7