Diagnosing PID (prolapse intervertebral disc)

Hi,

I would like to know how would u diagnose the level of PID only by examination..say by doing SLR or checking sensations etc.

Thanks,
Mona.

hi
it is not possible to find out the exact location of disc prolapse purely by physical examination.as you know in the acute stage of prolapse palpatory findings misguide you.slr is a general neural tensioner.it cant predict any location per se.again sensory motor issues is not mandatory in prolapsed disc scenario.

Thank you for replying linbin..

I disagree, u can diagnose where a prolapse disc is but i'd rather use the term protrusion as prolapse discs would most likely be sequestered anyway. Only in large derangements may the problem be difficult but then again sensory amd motor deficits will point to where the likely problem is. SLR is a neurodynamic test true, but it tests for the tension in the sciatic nerve so it helps to eliminate source when assessed with a prone knee bend(femoral nerve test). The physical examination of the spine is a full one just basing it alone on palpation and SLR is primitive.Palpation should be the very last thing done as your examination from history and physical would point to where u should palpate. U only get mmisguided when you palpate randomly first.Any swollen nerve root, if it is not the sheath alone that is damaged will refer where that nerve root goes. So true acute nerve root dural sheath lesions can be confusing because referal is everywhere, up and down and around the torso, howver if the root is affected then u can say where it is. in addition, ur examination should look at the sacroiliac joint, and hip to be sure it is not a misguided referal.

To me, I'd rather say PID is a MRI diagnosis. I would say to my client that he/she got segmental dysfunction....highly likely due to a discogenic problem.

Which is a very reasonable advice however as a care manager, medical cost to patient should be considered. If you can make a diagnosis based on clinical presentation then make it, moreover radiographic evidence cannot be trusted all the time. MRIs may introduce fear avoidance beliefs if they show something too interesting when in fact the interesting shots do not necessarily correlate with symptoms. So deciding whether to suggest MRI will depend on other factors as well.If symptoms are very clear, I do not think an MRI is needed, it may complicate issues.
I would suggest an MRI when I suspect something sinister going on and I can not put my finger on it.

"I disagree, u can diagnose where a prolapse disc is but i'd rather use the term protrusion as prolapse discs would most likely be sequestered anyway."
hello,
i am not getting what you are intending to say.prolapse can be subclinical.i not the least agree with you comment that disc might be sequestrated mostly.by doing prone knee bend you are checking for femoral nerve involvement.it doesnot help you to localise where the prolapse is,even in case of stenosis,mechanical sensitivity also neurodynamic test will be positive.

physical examination like doing SLR and other tests would definetly help to some extent to localize the source of symptoms.However to exactly find out the extent of severity and nature of lesion MRI has its own role.In some cases pain may limit the examination is such cases to radiological examination helps.So the physiotherapist should do the examination even if the physician has already diagonsed which helps him to formulate his hypothesis and work out on the cause.

hi friends
i think most of us come across patients whom physicians diagnosed as prolapsed disc based on MRI and postive findings like STRAIGHT LEG RAISING.
when you assess them you will not find any lumbar symptoms,normal and free glides.in them problem might be in the pelvic area.piriformis tightness might be the cause of neurodynamic test coming as positive.after stretching to piriformis ,within 1 session patient feels significant result
NOW DO YOU PEOPLE THINK THAT STRAIGHT LEG RAISING TEST WILL HELP TO DETERMINE THE LEVEL OF DISC PROLAPSE

To Linbin
the answer to that question is no, SLR alone cannot diagnose PID. All slr does is give you a picture of what is going on and possible areas to look. I think you have misread my information. the question is can you diagnose PID accurately and I think so. Because you can clinically reason what level with all ur tests and movements combined. We were discussing true PID and not other related casues from the SIJ, pelvis or hip.if you clinically reason those out then something must have thrown your thoughts away from the spine. If for example, you did not think it was any of these(hip etc) then something must tell you its the spine. You say there would be neural sensitivity, I do not disagree but the areas of referral will let you know where it is likely coming from.This is assuming there is a referral of course however combined movements and palpation can help clarify where. where the case becomes hard to discern is if the dural sheath is the only structure irritated, then the spread can be everywhere. on the issue of prone knee bend and SLR, those tests are quite sensitive therefore if you do find anything it rules in a likely PID but not specifically.At no point is it wise to base judgements on these two alone.Asking that question if SLR diagnoses PID is not a very accurate question to ask any physio because am sure everyone knows the answer is no.
Concerning the issue of a prolapse or protrusion, my point is the terminologies are often used for one another but they are two different conditions.in a prolapse disce, the annulus is torn therefore the pain the patient feel as compared to when stretched will be different. At no point have I said a prolapsed disc is subclinical(I dont even know what that means in a clinical context). I think with a prolapsed disc the symptoms are more specific as tension is taken away from the posterior structures that are sensitive and that makes it even easier to diagnose.
I agree with you that MRIs and SLRs are not enough to make judgements on a back problem.

The best way to determine level of PID by examination is testing miotomes, dermatomes and reflexes, while they give a mirror of level to which the nerve root compresion has occurred; always combining with SLR, palpation etc.

Hi all, particular thanks to limbin and Dr Damien.

The original question is how to diagnose PID from a clinical test.

I would say that the McKenzie Method has been shown to be fairly good at doing this. I am NOT mcKenzie Trained nor do i use it really but i appreciate the research that has been done that apparently supports the diganosis of disc involvement.

Other points to add...
1. SIJ as a pain producing structure does not refer to the L/S as shown by Fortin et al. HOWEVER, SIJ dysfunction can affect the pressure through the L/S and so cause disc pain. The same goes for hip etc.
2. I thought contralateral SLR usually indicated disc involvement i.e. left sciatica, right SLR <30deg = L sciatic symptoms. But i am not sure on that.
3. Groen et al have shown that the innervation to lumbar segments can be as far away as 4 levels above and 4 levels below - i.e. 8 levels possibly giving you pain at a spinal segment.
Cheers