Clinical Symptoms and Diagnosis of HNP

Clinical Symptoms
a. Low back pain is intermittent (within a few weeks to several years). Pain spreading according to the distribution of the sciatic nerve.
b. The nature of pain changed from lying to sitting position, ranging from back pain and continued to spread to the back and then to the lower leg.
c. Pain intensified as the originator of such movements waist when coughing or straining, standing, or sitting for long periods of time and reduced pain at rest or lying down.
d. Patients often complain of tingling (paraesthesia) or numbness even decreased muscle strength in accordance with the distribution of the involved nerves.
e. Pain increases when the L5-S1 region (line between the two iliac crest) is pressed.
f. If left unchecked, it will slowly lead to lower limb weakness / leg
g. conus or cauda equina if affected, can occur defecation disorders, micturition and sexual function. This situation is a neurological emergency that requires surgery to prevent permanent damage function.
h. Habits of patients need to be observed, when sitting more comfortable then sitting on the healthy side.
1. Anamnesis
a. Onset
Mechanical cause of the HNP, causing sudden pain arising after an adverse mechanical position. Possible muscle tear, stretching the fascia or irritation of the joint surface. Complaints arising from other causes gradual.
b. Duration and frequency of attacks
HNP due to mechanical causes lasting several days to several months. Herniation can discus takes 8 days to resolution. Disc degeneration can cause chronic discomfort with exacerbation for 2-4 weeks.
c. Location and spread
Most HNP due to mechanical or medical disorder mainly occurs in lumbosacral regions. Pain spreads to the lower leg or lower leg just lead to nerve root irritation. Pain that spreads to the limbs can also be caused by inflammation of the sacroiliac joints. Psychogenic pain does not have a fixed pattern of spread.
d. The factors that aggravate and mitigate
Mechanical lesions reduced complaints at rest and on exertion increases. In patients with HNP sitting slightly stooped aggravate the pain. Coughing, sneezing or Valsalva maneuver will aggravate the pain. In patients with tumors, more severe or persistent pain when lying down.
e. Quality / intensity
Patients need to describe the intensity of pain and can compare it with the passage of time. Must distinguish between the HNP with leg pain, which is more dominant and the intensity of each pain, which is usually the radicular pain. Pain in the legs more than the 80-20% ratio of HNP with radiculopathy showed and may require an operation. When HNP pain more than leg pain, usually do not indicate a compression of nerve roots and also usually do not require operative measures. HNP symptoms and intermittent long, punctuated by periods without symptoms are typical symptoms of the occurrence of an HNP mechanically.
Must also determine which movements can lead to increased pain HNP, ie sitting and driving and the pain usually decreases when lying down or standing, and any movement that could lead to heightened intra-abdominalakan pressure can add to the pain, as well as coughing, sneezing and straining during defecation.

2. Physical examination
a. inspection
- Active movement of patients should be assessed, watch movement which makes the pain and also the shape of the vertebral column, the reduced lordosis and the presence of scoliosis. Reduced by the loss of lumbar lordosis may be caused by spasm of the paravertebral muscles.
- The limitation of motion on one side or direction.
- Extension to rear often causes pain in the legs when in the lumbar intervertebral foramen stenosis and lumbar arthritis, because this movement will lead to a narrowing of the foramen causing compression of the spinal nerves.
- Flexion fore typically will cause pain in the legs when there HNP, because of the tension on the inflamed nerve over a discus protusio thus raising the pressure on the spinal nerves by increasing pressure on the depressed fragment adjacent (jack hammer effect).
- Location of HNP can usually be determined if the patient is asked to bend forward to the right and left lateral. Forward flexion, to a side or lateral to that cause pain in the ipsilateral limb indicates HNP on the same side.
- Pain HNP on the extension to the rear at a young adults showed the possibility of a spondilolisis or spondylolisthesis, however, is not pathognomonic.
b. palpation
- The pain / tenderness of the skin can indicate the possibility of an underlying psychological condition.
- Sometimes it can be determined where the segments that cause pain by pressing on the intervertebral space or by moving right to left to take look at processus spinosuss patient response. In the severe spondylolisthesis palpable presence of non-averaging (step-off) on palpation in place / level affected. With thumb emphasis on spinal processus done to look for a fracture to a vertebra. Other physical examination focusing on neurological disorders.
- Reflexes are decreased or disappeared symmetrically not so useful in the diagnosis of HNP and also can not be used to localize the abnormality level, except in the cauda equina syndrome or the same neuropathy. Patellar reflex mainly menunjukkanadanya disturbance of roots L4 and less than L2 and L3. Reflex predominant heel of S1.
- It must be sought as well as pathological Babinski reflex, especially when there hiperefleksia indicating the existence of a UMN disorder. Of this reflex examination can distinguish abnormalities that will be UMN or LMN.
- Check the motor must be done carefully and should be compared to the two sides to find a motor abnormalities as possible with respect to the mempersarafinya myotomes.
- Sensory examination will be very subjective as it requires the attention of the people and not infrequently mistaken, but remains an important diagnostic significance in helping to determine the localization of lesions corresponding dermatomes affected HNP. Sensory disturbances are more meaningful in showing the localization information, rather than motor.
- The signs of meningeal stimulation:
* Signs Laseque indicate a particular strain on the spinal nerves L5 or clinical signs S1. Laseque implemented with flexion at the knee first, then draped to 90 degrees and then slowly and gradual movement performed knee extension and this will result in pain in the limbs of patients especially in the calf and knee pain will be reduced when in a state of flexion. There is a modification of the test is to lift the leg with the knee in extension state (stright leg rising). Modifications laseque marks another all considered positive when causing a radicular pain. Laseque way that causes pain in the legs is a sign of possible contra lateral disc herniation diskus.Pada laseque mark, the smaller the angle made for a painful compression of nerve roots more likely as the cause. Similarly, the contralateral laseque mark. Laseque sign is a sign of pre-operative best for the HNP, which is seen in 96.8% of the 2157 patients who were operatively proven suffer HNP and the hernia is large and positive even complete this sign in 96.8% of patients. Laseque should note that the sign associated with age and are not so often seen in elderly patients compared to younger (<30 years).
* contralateral Laseque sign, implamanted in the same way, but if the leg pain is not removed will cause a positive response in the contralateral limb pain and indicate the presence of an HNP.
* Test Bragard modifications are more sensitive than tests laseque. Same way as the test laseque with dorsiflexion of the foot plus.
* Test Sicard as laseque test, but added toe dorsiflexion.
*  test the patient is asked to push Valsalva / cough and said to test positive if there is pain

3. Radiological Examinations
1. Plain vertebre
  Plain AP and lateral position of the lumbar spine and pelvis (sacro-iliac joints), Plain aims to see a narrowing of the disc, degenerative diseases, congenital abnormalities and unstable vertebrae.
In the case of disc bulging, plain radiographs showed no immediate overview of disc degeneration such as intervertebral disc height loss, a vacuum phenomen in the form of gas in the disk, and endplate osteophytes

In most cases hernia nucleus pulposus (HNP), plain photo lumbo sacral spine or cervical spine is not required. Photos can not show plain herniation, but used to get rid of other conditions such as, fractures, cancer, and infection.

1. CT scan
  is an effective diagnostic tool when the vertebrae and neurological level have a clear and likely due to bone disorders.

2. myelography
useful to see the roots of spinal disorders, especially in patients with previous spine surgery or with a metal fixation device

1. CT myelography
performed with a contrast agent is useful to see more clearly the presence or absence of nerve compression or arachnoiditis in patients undergoing spine surgery and when multiple operations will be planned action against the vertebral canal and foraminal stenosis.

1. MRI (73-80% accuracy)
Is a non-invasive examination, can provide a picture of the lining of the cross-sectional and longitudinal. Usually very sensitive to HNP and will show a variety of prolapse. But neurosurgeons and orthopedic surgeons still need an EMG to determine which are the most affected disc. MRI is especially useful when: vertebra and neurological level is not yet clear, suspicion pathological abnormalities in the spinal cord or the whole soft tissue determine the likelihood of postoperative herniation, suspicion for infection or neoplasm. On MRI, HNP appear as focal, asymmetrical bulge disc material beyond the boundaries of the annulus. HNP itself usually hipointense. In addition, free fragments of disc easily detected on MRI.

Regarding the limitations of MRI, in some individuals with implantable devices (eg, pacemakers) or with metal in the body, may not be able to perform MRI for pacemaker dysfunction or heating electrodes that may arise from the MRI. The doctor can instruct another examination.
According gradation, herniation of the nucleus pulposus is happening is divided into:
• Pro truded intervertebral disc, where the nucleus is visible protruding in a direction without damage to the annulus fibrosus.
• Pro lap sed intervertebral disc, where the nuclei move but still remains in the circle of the annulus fibrosus.
• Extruded intervertebral disc, which came out of the nucleus and annulus fibrosus under the posterior longitudinal ligament.
• Sequestrated intervertebral disc, where the nucleus has penetrated the posterior longitudinal ligament.

1. Myelography or CT myelography and / or MRI is a valuable diagnostic tool in the diagnosis of LBP and needed by neurosurgeons / orthopedic to determine the pre-operative localization of lesion and determine is there any discus sekwester off and exclude the presence of a tumor.

2. Mumenthaler (1983) mentioned the presence of 25% false negative myelography and disc prolapse at 10% false positive with 67% accuracy

3. Discography
Discography is a radiographic examination of the intervertebral discs with the help of x-ray contrast media and positive material is injected into the nucleus pulposus to determine the presence of a damaged annulus fibrosus, where contrast can only penetrate / break when there is a lesion by inserting a double needle to enforce diagnosis. With the MRI examination then this is not so popular anymore because invasive.

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