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Loss of Disc Height Between L1 – L2 Vertebra is a progressive, degenerative change on vertebrae with osteophyte formation in where the intervertebral disc spaces narrowing especially in elder people, or now the loss of bone height gradually decreases that is lead to nerve impingement, nerve entrapment with radiating pain, bone osteoporosis, loss of movement, bamboo spine or ankylosing spondylitis occurs in the spine, decrease range of motion, and joint inflammation and resultant pain, muscle spasm, muscle contracture can occur.

Intervertebral discs are pads of fibrocartilage that sit between the spinal vertebrae, occupying roughly one-third of the height of the spinal column.[rx] Their major role lies in the transmission of mechanical loading from body weight and muscle activity, allowing bending, flexion, and torsion of the bony spine.

Each disc consists of two main components: a central, gel-like substance called the nucleus pulposus, and outer, firmer annulus fibrosis. The consistency of the nucleus is a result of its water and proteoglycan content and is held together by a network of type II collagen and elastin fibers. The high anionic glycosaminoglycan content of this network gives the nucleus pulposus its osmotic properties, which allow it to resist compression. The annulus fibrosis is composed of bundles of type I collagen arranged in multiple oblique layers called lamellae. Characteristics of a normal, healthy disc demonstrate high water content in the nucleus and inner annulus. The most outer annulus provides tensile strength. Specifically, in the lumbar region, a healthy disc is typically 7-10 mm thick and 4 cm in AP diameter with approximately 20 layers of lamellae.[rx]

Causes For Loss of Disc Height Between L1 – L2 Vertebra

The Causes of Reduce or loss of loss of Disc Height Between L1 – L2 Vertebra are following

Repetitive trauma – such as poor posture, poor ergonomics, or repetitive heavy work can lead to reducing disc height or loss of disc height disc degeneration, and posterior disc bulging. These long-term injuries are often also associated with poor muscle strength, obesity, hypertension, diabetes, and other factors such as smoking.
An Injury caused – by sudden forces thrust or load on the disc such as a car accident or an awkward heavy lift. This sudden problem increase in pressure on the disc can cause damage and tears, reduce disc height or loss of disc height to the annulus that causes a posterior disc bulging, or bilateral disc bulging disc herniation, etc.
Spinal Degeneration – While some degeneration is a normal part of the aging process, poor spinal function, long-time disability, movement loss of spine and posture will dramatically speed up disc degeneration with a reduced disc height or loss of disc height.
People who have led a sedentary lifestyle or that – abnormal lifestyle such as driving, bicycling, walking uneven surface increases the chances for bulging disc and posterior disc bulging, with loss of disc height or reducing disc height.
Continuous strain on the disc from injury or heavy lifting – and strain can in case of playing such as cricket, football, basketball, hockey-playing, daily walking causes in wear them down throughout the years and may lead to posterior disc bulging, loss of disc height or reduce disc height.
Weakened back muscles – can accelerate the process of disc problem and may lead to a sudden herniation of the weakened disc to reduce disc height. Although bulging discs, loss of disc height, or reduce disc height occur over time, herniated discs may occur quickly by trauma with posterior disc bulging or bilateral disc bulging.
Bad posture – including improper body positioning during sleep, sitting, standing, traveling, or exercise are all factors that may contribute to the development of a loss of disc height or reduced disc height.
Obesity – Obesity is a complex disease involving an excessive amount of body fat. Obesity isn’t just a cosmetic concern. It is a medical problem that increases your risk of other diseases, back pain, degenerative spine, spondylosis, reduces disc height, health problems, such as heart disease, diabetes, high blood pressure, loss of disc height, and certain cancers.
Nutritional Influences on the disc – Inadequate supply of nutrients is an important factor contributing to degenerative disc disease, osteoporosis, decreased bone minerals. A metabolite gradient exists throughout the disc with minimal nutrients (glucose, oxygen) and high levels of lactic acid present within central regions. With degeneration, this metabolite gradient is exaggerated influencing the degenerative process. When the continued nutrient supply is reduced, cell death and altered matrix production decrease, matrix degradation, and endplate in vertebra borders change leading to further cell compromise and subsequent advancement of degeneration and loss of disc height.
High contact sports or activities – are also risk factors that may lead to an intervertebral disc problem, with reducing disc height or loss of disc height.
Runners who fail to use shoes that provide orthopedic support – may also develop bulging discs, reduce disc height due to accidents that cause abnormal fall down also cause loss of disc height.
Activities that place stress and strain on the spine – muscle spasm, contracture in backside, tendon, and cartilage erosion can lead to the weakening of bone blood vessels in vertebra of the reduced disc height or loss of disc height.
Mechanical back pain
Muscle strain
Osteophytes
Spondylolisthesis
Degenerative spinal stenosis
Cauda equina syndrome
Epidural abscess
Epidural hematoma
Diabetic amyotrophy
Metastasis
Ankylosing spondylitis
Synovial cyst
Neurinoma

Daily Unconscious Lifestyle That May Lead To

Vehicle accident
Already existing annulus weakness may cause loss of disc height
Body mechanics and poor posture put stress on the loss of disc height
Torsion of the disc from repetitive work with a lot of bending, twisting or lifting and reduce disc height, loss of disc height loss of disc height
Sitting, standing driving, or working for long periods of time may cause of loss of disc height
Sustaining back injury from a severe fall causes slipped disc, reduce disc height
Repetitive forceful motions in certain sports
Poor heavy lifting techniques, like bending forward to pull with your back can put sudden excessive load on the disc may cause loss of disc height
Abdominal fat and poor core stability
Reduced lower limb strength in elder people may lead to loss of disc height
People are genetically predisposed to have a lesser density of fibrocartilaginous fibers that make up the disc, reduce disc height, or loss of disc height.

What happens to discs during the process of aging and degeneration?

Cellular Changes – Approximately 1% of the intervertebral disc consists of cartilage-producing cells called chondrocytes. Overall there is a decrease in disc cell density, loss of disc height, and increased senescence of the cartilage cells to prevent reduced disc height. Loss of appropriately functioning cells, due to both necrosis and apoptosis, is present in both aging biology and matrix production. The loss of notochordal cells, which occurs with normal development in humans, and other chondrodystrophic species, contribute to the degenerative process with reduced disc height.
Disc Matrix Changes – Alterations in disc cell number and function, and cellular responses to nutritional deficiencies, loss of disc height turn, lead to alterations in both the cartilaginous and proteoglycan matrix components of the disc that lead to reduced disc height. Proteoglycan (PG) loss occurs due to their decreased production of disc cells and through increased expression of proteolytic enzymes. Loss of pivotal water-binding proteoglycan molecules leads to dehydration and collapse of the disc, loss of disc height, reduced disc height. Changes in the collagenous matrix components also occur leading to fibrosis of the disc. Alterations in the constituents of the matrix and decreased water content results in decreased flexibility and altered load distribution leading to cleft and fissure formation in both the NP and AF and occurs loss of disc height.
Endplate and Vertebral Body Changes – Bony endplate changes occur with thinning, calcification, and alterations in vascularity, leading to a decreased ability for the diffusion of nutrients and waste products of disc metabolism and causes loss of disc height. Change within the adjacent vertebral bodies also occurs, with evidence of sclerosis and bone micro-fracture. Osteophytes can also develop from the margins of the vertebral bodies and contribute to neural compression. In addition, degenerative changes are also evident in the corresponding facet joints, suggesting that disc degeneration is the primary event leading to the clinical condition of degenerative spondylosis with loss of disc height.
Neural and Vascular Changes – As disc degeneration progresses neo-vascularisation (blood vessel growth), with concurrent neo-innervation (a nerve growth), can occur within the degenerative disc. With the loss of the water-binding PGs from the disc, its capacity to absorb and efficiently distribute weight axial and rotational loads is diminished, resulting in additional mechanical stresses leading to concentric and radiating tears that may in the disc.
Mechanical Changes – The alterations in the disc matrix which occur with degeneration ultimately lead to abnormal biomechanics at the affected level and causes loss of disc height. The inability of the disc to function as a normal intervertebral motion segment and load distributor has critical implications for accelerating degeneration at both the affected level and adjacent levels, as well as precipitating pain in abnormally loaded structures, such as facet joints, ligaments, and paraspinal musculature.
Morphological Features of Disc Degeneration – Disc degeneration disrupts the normal architecture of the disc to varying degrees, the most severe of which lead to complete collapse of the disc, loss of disc height with loss of distinction between annulus fibrosus and nucleus pulposus. Eventually, ankylosis or auto-fusion of the spinal motion segment can occur in several losses of disc height.

Radiological Features of Disc Degeneration – Radiographic imaging plays a crucial role in the clinical assessment of back pain, disc degeneration, and other spinal pathologies.

Loss of disc height
Loss of high signal on T2-weighted imaging within the NP and inner AF (dehydration or desiccation of the disc)
Cleft formation and fissuring through the NP and AF
Loss of demarcation between NP and the inner and outer AF(45, 46)
Signal changes, termed Modic changes, within the adjacent vertebral bodies(47)

Reduce Disc Height

Symptoms Of Loss of Disc Height Between L1 – L2 Vertebra

Symptoms of Loss of Disc Height Between L1 – L2 Vertebra are following

Most commonly, posterior disc bulging, and reduce disc height creates pressure points on nearby nerves which create a variety of pain sensations due to loss of disc height.

Evidence of a reduced disc height – or loss of disc height may range from mild tingling and numbness to moderate or severe pain, depending on the severity of the intervertebral disc. In most cases, when a reduced disc height or loss of disc height has reached this stage it is near or at herniation.
Tingling or pain in the fingers, hands, arms, neck, or shoulders – This could indicate a bulging disc in the cervical area, and reduce disc height that may paresthesia in the following dermatome of corresponding nerve distribution.
Pain in the feet, thighs, lower spine, and buttocks – This is the most common symptom and could indicate an issue in the lumbar region pain, tingling, numbness, radiating pain in case of reducing disc height.
Pain may be a worsening – case of difficulty walking or feeling of impairment while lifting or holding things.
Loss of Bladder or Bowel Function – There are some bulging disc, reduce disc height, loss of disc height cases where professional care is essential. In some cases, such as when you lose bowel or bladder control, it is deemed an emergency, and you may require immediate surgery in some of the cases of loss of disc height.
Weakness in your limb muscles – is a significant concern that causes intense pain in the spine at any c1, c2, c3, c4, c5, c6,c7. If you experience arm, hand, leg, or foot weakness, please seek prompt medical assessment in case of reduced disc heights.
The reduced or altered sensation – it is your next priority. Mildly reduced disc heights can reduce your ability to feel things touching you, e.g. numbness or pins and needles in l1, l2, l3, l4, l5 vertebras for loss of disc height. If you experience any of the above symptoms, you should seek professional assistance.
Referred Pain – Pain in your limbs, e.g. legs in l1, l2, l3, l4, l5 vertebras for loss of disc height
(sciatica) or arms (brachialgia) is usually a more significant injury than when experiencing only spinal pain due to reduced disc heights. We recommend that you seek the professional advice of your trusted spinal care practitioner.
Spinal Pain – Interestingly, if you are only experiencing spinal pain, bulging discs are generally mild injuries and the most likely to rehabilitate quickly in l1, l2, l3, l4, l5 vertebras for loss of disc height. Please adhere to low disc pressure postures and exercise accordingly. If in doubt, please seek professional advice. Intermittent or continuous back pain. This may be made worse pain in l1, l2, l3, l4, l5 vertebras for loss of disc height by movement, coughing, sneezing, or standing for long periods of time. Spasm of the back muscles frequently may be feeling in daily activities
Sciatica Pain – that starts near the back or buttock and travels down the leg to the calf or into the foot for in l1, l2, l3, l4, l5 vertebras for loss of disc height.
Muscle weakness in the legs
Numbness in the leg or foot
Decreased reflexes at the knee or ankle
Changes in bladder or bowel function
Radicular pain in the distribution in l1, l2, l3, l4, l5 vertebras for loss of disc height
Sensory abnormalities at the lumbosacral nerve roots distribution
Weakness at the lumbosacral nerve roots distribution
Limited trunk flexion for causes intense pain in the spine at any c1, c2, c3, c4, c5, c6,c7
Pain exacerbation with straining, coughing, and sneezing
The pain intensified in a seated position, as the pressure applied to the nerve root is increased by approximately

Associate clinical feature is

Approximate area of “saddle anesthesia” seen from behind (yellow highlight)

Severe back pain Saddle anesthesia i.e., anesthesia or paraesthesia involving c1, c2, c3, c4, c5, c6, c7 dermatomes, including the perineum, external genitalia, and anus; or more descriptively, numbness or “pins-and-needles” sensations of the groin and inner thighs which would contact a saddle when riding a horse and causes intense pain in the spine at any c1, c2, c3, c4, c5, c6,c7.
Bladder and bowel dysfunction, caused by a decreased tone of the urinary and anal sphincters.
Detrusor weaknesses causing urinary retention and post-void residual incontinence as assessed by bladder scanning the patient after the patient has urinated.
Sciatica type pain on one side or both sides, although pain may be wholly absent causes intense pain in the spine at any l1, l2, l3 l4 vertebra
The weakness of the muscles of the lower legs (often paraplegia)
Pain in one leg (unilateral) or both legs (bilateral) that starts in the buttocks and travels down the back of the thighs and legs (sciatica)
Numbness in the groin or area of contact if sitting on a saddle (perineal or saddle paresthesia)
Bowel and bladder disturbances
Lower extremity muscle weakness and loss of sensations
Inability to urinate (urinary retention)
Difficulty initiating urination (urinary hesitancy)
The decreased sensation when urinating (decreased urethral sensation)
Inability to stop or control urination (incontinence)
Reduced or absent lower extremity reflexes
Local pain is generally a deep, aching pain resulting from soft tissue and vertebral body irritation.
Leg pain (radicular pain) is generally a sharp, stabbing pain resulting from compression of the nerve roots.
Radicular pain projects along with the specific areas controlled by the compressed nerve (known as a dermatomal distribution).
Inability to stop or feel a bowel movement (incontinence)
Constipation
Loss of anal tone and sensation
Achilles (ankle) reflex absent on both sides.
Sexual dysfunction
Absent anal reflex and bulbocavernosus reflex
Gait disturbance

These symptoms require immediate medical evaluation as they may be a sign of a potentially life-threatening condition.

Reduce Disc Height

Diagnosis Of Loss of Disc Height Between L1 – L2 Vertebra

The diagnosis of Loss of Disc Height Between L1 – L2 Vertebra is following

History

History in these patients should include the chief complaint, onset of symptoms, alleviating and aggravating factors, radicular symptoms, and any past treatments, and surgery intense pain in the spine at any c1, c2, c3, c4, c5, c6, c7. The most common subjective complaints are axial neck pain and ipsilateral arm pain or paresthesias in the associated dermatomal distribution to reduced disc heights in lumber rejoin of l1, l2, l3, l4.

Physical Examination

A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location, and reflex loss associated with the different levels are described above. A thorough neurological examination is necessary to evaluate sensory disturbances of intense pain in the spine at any c1, c2, c3, c4, c5, c6, c7, motor weakness and deep tendon reflex abnormalities of identifying loss disc heights. Typical findings of solitary nerve lesion due to compression by a herniated disc with bulging in the lumbar spine

Typical Findings Of Solitary Nerve Lesion Due To Compression By reduced disc heights In The Cervical Spine and pain may be radiating to the following rejoin

C5 Nerve – neck, shoulder, and scapula pain, lateral arm numbness, and weakness during shoulder abduction, external rotation, elbow flexion, and forearm supination. The reflexes affected are the biceps and brachioradialis.
C6 Nerve – neck, shoulder, scapula, and lateral arm, forearm, and hand pain, along with lateral forearm, thumb, and index finger numbness. Weakness during shoulder abduction, external rotation, elbow flexion, and forearm supination and pronation is common. The reflexes affected are the biceps and brachioradialis.
C7 Nerve – neck, shoulder, middle finger pain are standard, along with the index, middle finger, and palm numbness. Weakness on the elbow and wrist are common, along with weakness during radial extension, forearm pronation, and wrist flexion may occur. The reflex affected is the triceps.
C8 Nerve – neck, shoulder, and medial forearm pain, with numbness on the medial forearm and medial hand. Weakness is common during finger extension, wrist (ulnar) extension, distal finger flexion, extension, abduction, and adduction, along with distal thumb flexion. No reflexes are affected.
T1 Nerve – pain is common in the neck, medial arm, and forearm, whereas numbness is common on the anterior arm and medial forearm. Weakness can occur during thumb abduction, distal thumb flexion, and finger abduction, and adduction. No reflexes are affected.
L1 Nerve – pain and sensory loss are common in the inguinal region. Hip flexion weakness is rare, and no stretch reflex is affected.
L2-L3-L4 Nerves – back pain radiating into the anterior thigh and medial lower leg; sensory loss to the anterior thigh and sometimes medial lower leg; hip flexion and adduction weakness, knee extension weakness; decreased patellar reflex.
L5 Nerve – back, radiating into buttock, lateral thigh, lateral calf and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex.
S1 Nerve – back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot; weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.
S2-S4 Nerves – sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.

A physical exam for diagnosing disc pain may include one or more of the following tests

Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc, reduced disc heights.
Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a lumbar herniated disc (straight leg raise test) and reduced disc heights.
Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by a herniated disc, loss of disc height, and reduced disc heights at any c1, c2, c3, c4, c5, c6, c7. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine loss of disc height.

Special Manual Tests of spine

Neck Pain Maneuvers

Spurling’s maneuver – By turning your head and gently applying pressure, your doctor may reproduce radiating, nerve-related neck pain due to reduced disc heights or loss of disc height at any c1, c2, c3, c4, c5, c6, c7.
Manual neck distraction test – This test will help identify nerve pain in your neck. Your doctor will ask you to lift your head, which may relieve pressure on compressed nerves to detect reduced disc heights at any c1, c2, c3, c4, c5, c6, c7.

Low Back And Leg Pain Maneuvers

Femoral stretch test – While lying face down, your doctor will flex each knee to determine if you feel pain in your thigh. If you do, this indicates nerve compression in your lumbar spine at any lumber rejoin of l1, l2, l3, l4.
Schober test – This test examines the range of motion in your lumbar spine. During this test, you will bend over, as if you are trying to touch your toes.
Trendelenburg test – This test can identify weakness in the muscles that support the hip. In this test, you’ll stand straight on one leg for 30 seconds. Your doctor will observe if your pelvis stays level lumber rejoin of l1, l2, l3, l4.

Provocative Tests In A Spinal Examination

Shoulder Abduction (Relief) sign – Active abduction of symptomatic arm achieved by patient placing their ipsilateral hand on their head. A positive test results in relief (or reduction) of cervical radicular symptoms.
Neck Distraction test – Active distractive force is applied by the examiner while grasping the patient’s head under the occiput and chin. A positive test results in relief (or reduction) of cervical radicular symptoms.
L’hermitte’s sign – Examiner passively flexes patient’s cervical spine. A positive test result is an electric shock-like sensation down the spine or extremities.
Hoffman’s sign – Passive snapping flexion of distal phalanx of patient’s middle finger. A positive test results in flexion-adduction of the ipsilateral thumb and index finger.
Adson’s test – Patient is instructed to inspire with chin elevated, and head rotated to the affected side. A positive test results in obliteration of radial pulse.
The Spurling test – is designed to reproduce symptoms by compression of the affected nerve root. The cervical extension is used to induce/reproduce posterior bulging of the intervertebral disk. Rotation of the head causes narrowing of the neuroforamina in the cervical spine. Finally, axial compression is applied to amplify these effects with the aim of exaggerating the preexisting nerve root compression.
The prone instability test – The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso onto the couch. The patient can hold onto the couch’s sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine, while the feet are off the floor, is considered positive. [rx]
Prone Plank/Bridge – The patient is prone and elevates his / her entire body off the couch/mat on forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.[rx]
Supine Bridge – The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- the 30s. [rx]

Clinical Tests For Instability

Aberrant movement on flexion-extension – The standard examination involves documenting the range of movement. The quantitative range of movement may not be as significant as the qualitative range of movement. The important feature of spinal instability is the aberrant motion that occurs when flexing and extending the spine. A catch, a painful arc, supporting the arms on the thighs, or a reversal of the lumbopelvic rhythm when standing from the flexed posture indicates instability.[rx]
Passive lumbar extension test – The subject lies on the examination couch. The examiner passively lifts the lower limbs to a height of 30 cm from the coach while maintaining the knee in extension and applying gentle traction on the legs. A positive test is recorded if the patient complains of “pain in the lower back region” or complains of “heaviness in the lower back” or complains that, “the lower back is coming off.” These experiences should return to normal when the leg returned to the couch. The passive lumbar extension test has the highest combined sensitivity and specificity and may be comparable to radiological findings to identify lumbosacral structural instability.[rx]
The prone instability test – The patient stands at the foot end of the examination couch. The patient then lowers his/her upper body to rest on the examination couch. The iliac crest should rest on the edge of the examination couch. The patient holds the sides of the examination couch for increased stability. In the first part of the test, the feet of the patient are resting on the ground. The examiner with the heel of his/her hand creates a small posterior to anterior trust at each segment of the lumbar spine. Pain, if experienced by the patient, is recorded. In the second part of the test, the patient is asked to lift the feet of the floor and steady himself /herself by holding onto the sides of the examination couch. The examiner again repeats the posterior to anterior trust with the heel of his/her hand at each lumbar segment. The test is positive if the pain created in the initial part of the test subsides when the extensor muscles of the spine are tensed by lifting the feet of the floor.[rx]

Clinical Tests For Endurance

Sorensen test – The legs of the patient are strapped onto a low platform, which is only 25 cms above the floor. The upper end of the iliac crest is aligned to the edge of the table. The upper torso rests on the floor. At the commencement of the test, the patient extends the spine and lifts the upper torso off the floor with the arms crossed across the chest, and is asked to maintain the horizontal position. The record of the time, the patient can maintain this position is documented. Normative values: Men 146 +/- 51. Women 189 +/- 60.[rx]
Prone isometric chest raise – The patient lies prone on the examination couch with a pad underneath the abdomen and the arms along the sides. The patient is instructed to lift the upper trunk about 30 degrees from the table while keeping the neck flexed, and the intention is to hold the sternum of the surface of the couch. The clinician records the maximum time that the patient can hold this position. [rx]Normative values: Men 40 +/- 9. Women 52 +/- 18.[rx]
Prone double straight leg raise – The patient lies prone on the examination couch with the hips extended and the hands underneath the forehead. The arms are perpendicular to the body. The patient is then requested to lift both the legs off the couch until the knee is cleared off the couch. The patient should maintain normal breathing during the entire test procedure. The examiner can monitor the knee clearance by sliding a hand under the knee. The clinician records the maximum time that the patient can hold this position. Normative values: Men 38 +/- 6. Women 35 +/- 5. The prone double straight leg raise has shown to have great sensitivity and specificity. [rx]
Supine static chest raise – The patient lies supine on the couch with the legs extended. The hands are placed on the temples with the elbows pointing to the ceiling. The patient is then instructed to lift the head, the arms and the upper trunk of the couch. The patient should maintain normal breathing during the entire test procedure. The clinician records the maximum time that the patient can hold this position. Normative values: Men 43 +/- 9. Women 32 +/- 5. [rx]
Supine double straight leg raise – The patient lies supine with the legs extended, and the arms crossed in front of the chest. The pelvis is tilted forward to increase the lumbar lordosis. The patient is then requested to lift both the legs of the floor for 30 degrees while maintaining normal breathing during the entire test procedure. To monitor the pelvic tilt, the examiner can place one hand under the lumbar spine. The clinician records the maximum time that the patient can hold this position. Normative values: Men 28 +/- 4. Women 28 +/- 4. [rx]
Flexor endurance test – The patient is supine on the couch with the upper part of the body propped up on a support. The support is at an angle of 60 degrees. The legs are flexed so that the knee is at a 90-degree angle with the foot flat on the couch. The toes and feet are strapped to the couch to provide a counterbalance. In a modified procedure, the examiner sits on the edge of the couch and over the toes of the patient to provide a counterbalance. The arms are crossed across the chest towards the opposite shoulder. The support is moved back by 10 cms, and the patient is instructed to maintain the original position. The clinician records the maximum time that the patient can hold this position. Normal values: Men 144 +/- 76, Women 149 +/- 99 in normal subjects.[rx]
Prone Plank/Bridge – The patient lies prone on a mat. Initially, the patient lifts his / her upper torso off the mat and steadies on the elbows and forearms. The elbow is directly below the shoulder, and the forearms are straight with hands in front of the elbow. The patient then lifts the pelvis off the mat. The body is now supported on the elbow/forearm and the tips of the toes. The patient maintains a rigid horizontal position parallel to the floor. The clinician records the maximum time that the patient can hold this position. Normative values: Men 124 +/- 72s, Women 83 +/- 63s.[rx]
Supine Bridge – The patient lies supine with the legs flexed so that the knee is at a 90-degree angle, and the foot is flat on the couch but not touching each other. The elbows are bent, and the hands are placed on the ears. The patient then lifts the pelvis so that the shoulders, hips, and knees are in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 188 +/- 45s, Women 152 +/- 30s.[rx]
Side Plank/Bridge – The patient lies on the side of a mat. The upper part of the body is lifted off the mat and supported on the elbow of the arm below. The opposite (upper) arm crosses across the chest onto the lower shoulder. The top foot is positioned in front of the lower foot. The patient is then instructed to lift the pelvis off the floor and to maintain the trunk and the legs in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 95 +/- 35s, Women 74 +/- 33s.[rx]

Waddell Signs Include

Superficial tenderness – The patient’s skin over a wide area of the lumbar skin is tender to light touch or pinch.
Non-anatomical tenderness – The patient experiences deep tenderness over a wide area that is not localized to one structure and crosses over non-anatomical boundaries.
Axial loading – Downward pressure on the top of the patient’s head elicits lumbar pain.
Acetabular rotation – Lumbar pain is elicited while the provider passively and simultaneously externally rotates the patient’s shoulder and pelvis together in the same plane as the patient stands. It is considered a positive test if pain occurs within the first 30 degrees of rotation.
Distracted straight leg raise discrepancy – The patient complains of pain during a straight leg raise during formal testing, such as when supine, but does not on distraction when the examiner extends the knee with the patient in a seated position.
Regional sensory disturbance –The patient experiences decreased sensation fitting a stocking-like distribution rather than a dermatomal pattern.
Regional weakness – Weakness, cogwheeling, or the giving way of many muscle groups that are not explained on a neuroanatomical basis.
Overreaction – A disproportionate and exaggerated painful response to a stimulus that is not reproduced when the same provocation is given later. These responses can include verbalization, facial expression, muscle tension, or tremor.[trx],[rx]

Straight Leg Raising Test

The straight leg raising test was described by JJ First in his doctoral thesis in 1881. He attributed the test to his teacher Charles Lasègue, hence called the Lasègue sign. He attributed the sign to be due to compression of the sciatic nerve by the hamstrings. In 1884, de Beurmann in a cadaveric study identified the stretching of the sciatic nerve by straight leg raising and attributed the pain to the stretching of the sciatic nerve.
Done with the patient supine. Raise the affected side with the knee in extension. Positive if the patient complains of pain in the back of thigh radiating into the calf.
True positive SLR is exacerbation or reproduction of pain radiating along the back of the thigh into the calf in the symptomatic side at 0-700 of limb elevation. It is a test of nerve root irritation. If a patient complains of pain in the back or gluteal region, then the test is a false positive.
It is highly sensitive for lower lumbosacral root compressions (0.80-0.97) but low specificity (0.40). Hence a negative SLR is more important clinically than a positive SLR.

Verification Of SLR

Verification of SLR was done to differentiate between pain due to hamstring tightness and sciatica. Verification manoeuvre Do SLR. Flex the knee slightly when pain is produced, pain disappears the limb can be raised further. Pain persists if false positive.

Variants Of SLR Test

Crossed SLR – Described by Fajersztan. Raising of straightened contralateral limb produced symptoms on the symptomatic side. Has a high specificity of 0.90.
Bragaard’s test– Described by Fajersztan. Do SLR. Lower the limb slightly when pain is produced, dorsiflex the ankle. Pain reproduced if positive.
Bowstring test– Do SLR. Lower the limb slightly when pain is produced, Pain disappears. Press on the popliteal fossa. Pain reproduced if positive.
Cross-over sign– Do SLR. pain radiates into the affected limb and the opposite limb. Indicates a midline lesion, severe enough to compress nerve roots on both sides.

Slump Test

Position of patient – Seated upright.
Position of examiner – Standing on the side of the patient
Procedure – Ask the patient to slump first. If pain is not produced then ask the patient to bring his head onto the chest, extend his knee and dorsiflex his ankle one step at a time.
Interpretation – Provocative sciatica is taken as a sign of neuromenigeal irritation.
Use – Used as an alternative for the SLR test.

Quadrant Test

Position of patient – Standing
Position of examiner – Standing behind the patient
Procedure – Keep one hand over the patient’s contralateral shoulder and apply axial pressure. Ask the patient to hyperextend, rotate and laterally flex to the contralateral side.
Interpretation – Provocative pain is taken as a sign of lumbar instability.
Use – Used if pain cannot be produced by forwarding flexion, lateral flexion etc.

Reduce Disc Height

Adams Forward Bending Test

Position of patient – Standing with feet together, knee extended.
Position of examiner – Standing behind the patient first then in front of the patient.
Procedure – Rule out limb length discrepancy. Ask the patient to bend forwards at the waist till the back is in the horizontal plane. Palms should be held together.
Interpretation – If there is a rib or loin hump present, then there is structural scoliosis with rotation.
Use – To differentiate between structural and non-structural scoliosis.
Validity of test – For a patient with 40 structural scolioses, the test has a sensitivity of 0.83 and a specificity of 0.99.

Lab Test

A medical history – in which you answer questions about your health, symptoms, and activity.
A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
Elevated CRP – levels are associated with infection.

Imaging

X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, or fractures. It’s not possible to diagnose a herniated disc with this test alone.
Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with a bulging disc. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression. It can also detect bony overgrowth, spinal cord tumors, or abscesses.
A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, a bulging disc in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, spinal cord tumors, and abscesses. A CT scan may follow this test.
Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc is damaged.
Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc.
Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure.

Reduce Disc Height

Treatment Of Loss of Disc Height Between L1 – L2 Vertebra

The following treatment for Loss of Disc Height Between L1 – L2 Vertebra is

Non- Pharmacological

Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support in case of reduced disc heights
Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of disc bulges, reduced disc heights. Heat application in the later stages of treatment also provides the same benefit.
Hot Bath – Taking a hot bath or shower also helps in dulling the pain from a disc bulge and reduced disc heights. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period and reduced disc heights
Traction – May be beneficial in reducing the radicular symptoms associated with disc herniations increase reduced disc heights. Traction is the best essential treatment for bulging discs, pinched nerves, radiating pain management. It can be done in a manual and dynamic way to relieves pain in bulging discs and reduced disc heights. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
Massage therapy – may give short-term pain relief, increase disc space and prevent reduced disc heights but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower back pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
Acupuncture – may provide some relief for the back, and reducing disc height pain. However, further research with stronger evidence needs to be done. Acupuncture is a technique that involves inserting very thin metal needles into the skin at precise points on the body to clear energy channels, with the aim of restoring and maintaining health. The spots of insertion are picked based on a complex network of lines of energy, termed meridians. Meridians are thought to encircle the body like global lines of longitude and latitude. Acupuncture is a mainstay of traditional Chinese medicine, which has been practiced for thousands of years.
Spinal manipulation – is a widely-used method of treating back pain, reducing disc height pain although there is no evidence of long-term benefits. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, reducing disc height pain, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
Back school – is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective in case of reducing disc height pain.
Patient education – on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk, or reducing disc height pain)
Physical therapy – which may include ultrasound, massage, conditioning, and exercise. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury, and reducing disc height pain. Physical therapists can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness, and reducing disc height pain.
Over the Door Traction – This is a very effective treatment for a disc bulge. It helps in relieving muscle spasms and pain. Typically a 5 to 10-pound weight is used and it is important that patients do this under medical guidance.
Weight control – By keto diet or maintaining or changing the food habit to reduce the weight not any movement during the time of acute pain, and reducing disc height pain.
Use of lumbosacral back support – Also known as lumbar sacral orthoses (LSOs), sacroiliac belts, lumbar belts, lumbar corsets, occupational braces, low back braces, and back supports. These lower back supports help to provide relief from back pain in the lumbar spine, pelvis, and sacroiliac joints and helps to alleviate symptoms.
Maintaining a Healthy Weight – Excess weight means your spinal discs are absorbing extra stress with every step you take. Maintaining a healthy weight will help reduce the load your spine bears over the years to maintain proper disc height.
Posture Care – Whether you’re working on the job or reading on the couch, you’ll want to be aware of your posture and make corrective changes. Staying in one position too long or having poor physical mechanics when moving can put added stress on certain spinal discs and contribute to degeneration and height loss.
Typically – conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.
Exercise – is very important in helping prevent early spinal disc height loss. Exercise will help to strengthen key spinal structures so they can properly handle stress, which in turn can keep some stress off your discs. Strive to get regular exercise to help protect your discs and increase disc space.
Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal back pain of all types. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.

Medications

Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
Muscle Relaxants – These medications provide relief from spinal muscle spasms. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib , ibuprofen, and naproxen.
Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
Dietary supplement – to remove general weakness & improved health.
Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
Oral Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
Steroid injections The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves (Fig. 3). About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.
- epidural steroid injection. A steroid solution is injected into the epidural space (outer layer of the spinal canal) to reduce inflammation. This injection is by far the most common one used for herniated discs.
- Selective nerve root injection. A steroid solution and anesthetic is injected near the spinal nerve as it exits through the intervertebral foramen. This injection is also used to help diagnose which nerve root might be causing pain.

Brief Surgical Techniques

Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF) – Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove the affected disc and to increase the disc height. The posterior longitudinal ligament can be left in situ depending on the severity of the herniation prevention, increase the disc height. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed in case of disc height reduction. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage to increase the disc height. Although complications are rare, patients experience dysphagia, hoarseness, and transient sore throat. Adjacent segment disease or pseudoarthrosis can occur depending on the severity and number of levels operated. The majority of patients get symptomatic relief and can resume full activity after six months.
Laminectomy – A cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression. Single-level cervical disc herniation, reduce disc height is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, reduce disc height and occipital headaches.
Laminoplasty – The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina. Laminoplasty is commonly indicated for multilevel spondylotic myelopathy, reduce disc height. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.

References