title: Clinical diagnosis of upper lumbar disc herniation: Pain and/or numbness distribution are more useful for appropriate level diagnosis.
abstract: OBJECTIVE
  The purpose of this study is to disclose the characteristic symptoms and signs in L2, L3 and L4 nerve root disturbance.
  
  
  METHODS
  Fifty eight patients who underwent lateral herniotomy were analyzed. Breakdowns are 15 patients with L2/3 lateral disc herniation (group A), 20 patients with L3/4 lateral disc herniation (group B), and 23 patients with L4/5 lateral disc herniation (group C). The following items were examined: 1) localization of the subjective pain and numbness, 2) objective neurological findings, including deep tendon reflex, manual muscle strength (MMT), straight leg raising test (SLRT) and femoral nerve stretch test (FNST).
  
  
  RESULTS
  In group A, subjective pain and/or numbness was present in the thigh aspect, proximal to the knee joint in all patients. In group B, 80% of the patients had subjective pain and/or numbness in the medial site of the knee joint. In group C, the subjective pain and/or numbness was localized in various aspects of the lower extremity. Weakness in the iliopsoas, the femoral quadriceps, and the anterior tibial muscle were observed in 60-95%, 27-70%, 0-43% of three groups, respectively. Depression or absence of the patella tendon reflex was present in 27-100% of three groups. SLRT and FNST were positive in 13-87% and 91-95% of three groups.
  
  
  CONCLUSIONS
  Symptomatic levels of nerve root disturbance in the upper lumbar spine could not be accurately identified by objective neurological findings alone. Pain and/or numbness localized in the thigh area proximal to the knee joint is a specific sign of L2 nerve root disturbance. Either subjective pain or numbness in the medial knee joint aspect is another key sign which strongly suggests L3 nerve root disturbance.
authors.affiliation: Department of Orthopedic Surgery, Akita Rosai Hospital, Japan. Electronic address: takido@poplar.ocn.ne.jp.
authors.forename: Tadato
authors.initials: T
authors.lastname: Kido
authors.affiliation: Department of Orthopedic Surgery, Akita Rosai Hospital, Japan.
authors.forename: Koichiro
authors.initials: K
authors.lastname: Okuyama
authors.affiliation: Department of Orthopedic Surgery, Akita Rosai Hospital, Japan.
authors.forename: Mitsuho
authors.initials: M
authors.lastname: Chiba
authors.affiliation: Department of Orthopedic Surgery, Akita Rosai Hospital, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Sasaki
authors.affiliation: Department of Orthopedic Surgery, Akita Rosai Hospital, Japan.
authors.forename: Nobutoshi
authors.initials: N
authors.lastname: Seki
authors.affiliation: Department of Orthopedic Surgery, Akita Rosai Hospital, Japan.
authors.forename: Keiji
authors.initials: K
authors.lastname: Kamo
authors.affiliation: Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Japan.
authors.forename: Naohisa
authors.initials: N
authors.lastname: Miyakoshi
authors.affiliation: Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Japan.
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Shimada
mesh_terms: D005260:Female; D006801:Humans; D006987:Hypesthesia / Q000175:diagnosis / Q000209:etiology*; D007405:Intervertebral Disc Displacement / Q000150:complications* / Q000175:diagnosis* / Q000503:physiopathology; D017116:Low Back Pain / Q000175:diagnosis / Q000209:etiology*; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D053580:Muscle Strength; D011843:Radiculopathy / Q000175:diagnosis / Q000209:etiology*; D012189:Retrospective Studies; D012680:Sensitivity and Specificity