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Prolapsed disc may press on the duramater causing backache or on the nerve roots causing backache or sciatica or both. The prolapse of a disc occurs nearly always just above or below the 5th lumbar vertebra (i.e. between L4 and L5 or L5 and S1). As oedema subsides the prolapsed disc may shrink or slip back into place. Sometimes it may not be absorbed and becomes adherent to root sheaths. Long standing prolapse may disturb the mechanism of the intervertebral joints. The first attack is often sudden in onset and occurs while lifting weight from bent position. The patient complains of excruciating backache and sciatica may or may not follow soon after. The symptoms subside in a few days or weeks. Sciatica is at first locate in the buttock but it soon spreads to the thigh, leg along the posterior aspect even upto the toes. Subsequent attacks are also sudden in onset but may follow trivial injury such as coughing etc. On examination,. the patient is found to stand with a characteristic attitude - lumbar scoliosis with convexity to the affected side. kyphosis and slight flexsion of the hps and knees. Local deep tenderness is elicited on or slightly lateral to the affected spine. Pressure on the jugular vein often induces pain over the lesion (Naffziger's test). Flexion and extension of the spine are greatly restricted. Lateral flexion on the side of the lesion is also very painful, but rotation may be free and painless. Knee jerk may be diminished (in case of lesion between L3 and L4), but tendo Achillis jerk is almost always absent. Extension of the great toe against resistance will show weakness of the extensor hallucis longus. This indicates nervous involvement. After first attack there may not be any X-ray changes. But after many months or years with subsequent attacks there will be narrowing of the intervertebral space with lipping of the vertebral bodies, i.e. secondary osteoarthritic changes develop. Myelography is helpful in diagnosing this condition. Recently discography is often done to delineate the protrusion of the disc. Epidurography is also helpful so far as the diagnosis of this condition is concerned. MRI is probably the best method of investigation at the present.
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