Degenerative back disease in L1 and L2
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The intervertebral disc is responsible for joining and cushioning the vertebral bodies.
The system of vertebrae and discs provide flexibility, shock absorption, and load distribution. With age, discs undergo changes in biochemical composition. Lumbar disc herniation is a result of degeneration of the outer ring of the disc- the annulus. This leads to a weakening of the anulus, making the disc susceptible to tearing.
Symptoms of a herniated lumbar disc may often be difficult to distinguish from that of other spinal disorders.
Several factors, including genetic factors and changes in water content and collagen, are believed to play a role in the development of degenerative disc disease. Water-binding capability of the nucleus is important for the health of the disc. In the healthy disc, the inner portion of the disc- the nucleus -distributes the forces equally throughout the anulus. Reduced disc hydration lessens the cushioning effect, thus transmitting loads to the anulus in a manner that leads to injury.
The symptoms related to spinal disorders must be differentiated from those of other potentially serious systemic conditions, including metastatic and rheumatologic disorders. Fracture and infection also need to be considered.
The most common levels for a herniated disc are L4-5 and L5-S1. The onset of symptoms are a sharp, burning, stabbing pain radiating down the posterior or lateral part of the leg, to below the knee.
Physical examination can point to diagnosis. Pain during low back flexion indicates discogenic pain, while pain on extension can occur with facet disease. Ligament or muscle strain can cause pain when the patient bends to the opposite side.
The upper lumbar region (L1, L2 and L3) controls the iliopsoas muscles, which can be tested by resistance to hip flexion. Pain and weakness indicate upper lumbar nerve root involvement. The L2, L3 and L4 nerve roots control the quadriceps muscle, which can be tested by trying to flex an extended knee. The L4 nerve root also controls the tibialis anterior muscle, which can be tested by heel walking.
With disorders higher up such as degenerative back disease at L1 or L2, the patient may complain of pain in the lower abdomen, the groin, or the testicles. The pain is a deep aching sensation, and feels exactly like the pain produced by visceral disorders.
The pain felt by the patient may suggest an intestinal, urological, testicular, or gynecological disorder.
This pain is called "pseudovisceral pain". The intensity ranges from mild to severe. It may occur only episodically. There may be no awareness that the pain is triggered by mechanical causes (exertion; position).
Patients with degenerative back disease at the lower thoracic and upper lumbar region can also present with pain in the lateral hip that is made worse by walking; some may complain of groin pain. These symptoms can suggest a hip condition.
In some cases, the pain will radiate into the lateral thigh, mimicking sciatica.
With disc problems at T12-L1, pain is felt in the inguinal region and medial thigh with no motor abnormality noted.
With disc problems at L1-2, pain is seen at the anterior and medial thigh with slight weakness noted in the quadriceps.
With disc problems at L2-3, pain is felt in the anterior and lateral thigh with weakness in the quadriceps muscle. There is a weakened patellar reflex.
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