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Disk Herniation: Clinical Presentation and Diff Dx

- See: Discogenic Pain:

- Discussion:
    - predominence of leg pain (nerve pain) over back pain (usually annular pain);
    - determine if leg pain is made worse by activities or positions that increase intra discal pressure;
    - SLR: is key finding in sciatica, but is also found in:
            - myogenic pain;
            - ischial burisitis;
            - annular tear;
            - hamstring tightness;
            - critical distinction is made by the sciatic stretch test;
                 - test is performed after SLR by lowering affecting leg few deg below point that produces leg pain & then dorsiflexing ankle;
                 - for this test to be pos for dx of herniated disc, leg pain must be greater than back pain;
     - neuro exam demonstrates reflex changes, weakness, or seg sensory loss;
            - diminished ankle jerk compared to opposite side identifies S-1 lesion;
            - weakness of great toe extension identifies an L5 lesion;
     - sensation is diminished on medial side of foot & lateral calf for
            L5 lesions & on lateral foot & posterior calf for S1 lesions;
            - stocking hypesthesia, even envolving entire leg, is not necessarily a sign of hysteri or mlingering.
     - caudal equina syndrome:
            - should be considered in any patient w/ back pain, especially if disc herniation is present;

- Differential Diagnosis:
    - epidural abscess
    - epidural hemorrhage;
    - ankylosing spondylitis
    - multiple myeloma
    - vascular insufficiency
    - arthritis of the hip
    - osteoporosis with stress fractures
    - extradural tumors
    - peripheral neuropathy
    - herpes zoster

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